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2016-599-E Finance - OCIM Meals on Wheels - Outside Agency Performance Agreement
DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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-Meals on Wheels, 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-Meals on Wheels agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2016 to June 30, 2017. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit"A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 17000. 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 $4,250. 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. (Orange Congregations in Mission-Meals on Wheels) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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. (Orange Congregations in Mission-Meals on Wheels) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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. (Orange Congregations in Mission-Meals on Wheels) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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-Meals on Wheels provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Orange Congregations in Mission-Meals on Wheels) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E County: Finance&Administrative Services Provider: Orange Congregations in Mission- Orange County Meals on Wheels 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 Eire ox••`�..hai Qsf ithe Provider . S a t S. F f. 10/27/2016 RFfi9FCFIlfiZ544R1 For and Date Ltu1.eho f f Orange County Government tka"mt-I'Stt,t1 10/31/2016 8637991 B755E177... Bonnie Hammersley, County Manager Date (Orange Congregations in Mission-Meals on Wheels) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E ATTACHMENT "A" Orange County Certifications—FY 2016-17 Outside Agency Performance Agreement Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title,residential address;phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DocuSigned by: StarotA, S. F I. Executive Director 10/27/2016 Certified by: Title: Date: $E6PECGDG75A483... (Provider's Signature) (Orange Congregations in Mission-Meals on Wheels) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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) Meals on Wheels 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. xType 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:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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. xArticles 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 9:29:51 AM 0 I:° 2 of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider'saNdiOcriatooliication 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: 919-731-6194 ext. 10 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: Meals on Wheels Project/Program Primary Contact and Title: Kay Stegner, Manager of Client Services Telephone Number: 919-732-6194 ex.12 E-Mail: ocimsrmembargmail.com c) Funding Request Identification Total Project/Program Cost: $61,732 Total Amount of Funds Requested: $17,000 Proposed Use of Funds Requested(2-3 Line Maximum): Purchase catered meals for Meals on Wheels recipients who are unable to pay the entire amount of the meal. Though the cost charged for meals is $2.80, actual cost of a meal is $3.25; $17,900 would subsidize 17 people for one year. 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. LI CDBG Non-Construction (CH) $ n Grant I Loan LII CDBG Construction (CH) EI Grant n Loan 0 HOME CHDO (OC) I I Grant Lii Loan 0 HOME Other(OC) E Grant E Loan X Human Services: n Carrboro $ El Chapel Hill$ X Orange County$17,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. e' if fie Signature: ( ) E cutive Directoi Date Signature: cc 7-47/ 7 Board Chairperson Da e Main 4nnliratinn 101/71)16 1n..1Q- 7 AM P :4 ri r) f DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's aNAAgEafaiigication 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 Ti 7,17a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? 111 iI b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? E1/c) Current beneficiaries of the project/program for which funds are requested? El 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, ) ()),&,_ j-/.__e:((2 / Executive Director Date Signature: (11a2" Board Chairperso D Main 4nnliratinn 1/7117n1R Q.R"4..cF 4AA P a' 9 9 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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 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. Samaritan Relief Ministry: Provides emergency food, utility and rental payment, and prescription medication payment. 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 Orange Congregations in Mission's involvement in Meals on Wheels began in 1981. At that time the program was strictly volunteer run. In October 2001, OCIM hired the first part-time Meals on Wheels Coordinator. The current Meals on Wheels Coordinator has been with the program for 10 years. During that time the program has become very efficient, with nearly immediate turn-around from interview to meal delivery for qualified referrals. Computerized driver's directions have made it easy to add new recipients onto existing routes. Driver retention and delivery reliability has improved as well. 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 9:29:51 AM P of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION Main Application 5/25/2016 9:29:51 AM .. 5 o of 2 2 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Orange Congregations in Mission Meals on Wheels 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 X X X Job Training Sports and Arts Activities Pre-School Activities After-School Activities Mentoring Transportation Housing Other: Please specify Program/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b) Summarize the program services proposed and how the program will address the chosen Town/County priority? Only applying for county funds. 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 Meals on Wheels program provides a nourishing lunch, five days a week to homebound residents of northern Orange County. According to Orange County's Master Aging Plan, The number of adults age 65+ in Orange County is estimated to increase by Main Application 5/25/2016 9:29:51 AM P 6 of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION 31% between 2012-2017. By 2030, this population will more than double from its size in 2012, reaching an estimated 31,063 people and making up 17.6 of all Orange County individuals. Orange Congregations in Mission's Meals on Wheels program desires to make sure the most fragile members of the northern Orange County communities receive a home-delivered lunch and accompanying visit by the delivery volunteer. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. The people who qualify for OCIM's Meals on Wheels program are home alone during the day, unable to prepare a nutritious meal for themselves due to either physical or cognitive disability, and are no longer driving. The individuals this program serves are normally unable to participate in the programs available at the Central Orange Senior Center. Many of the Meals on Wheels recipients are very low income, though the program is open to any person who meets the qualifications. Ideally, if a person has the financial resources available, other options are available. When the Meals on Wheels Coordinator receives a referral, she calls either the person needing the service or an identified family member. Basic questions are asked, including where in Orange County they live. If it appears the person meets the qualifications, the coordinator goes to the home to get clear directions and to discuss the financial sliding scale. e) Who specifically will carry out the activities and in what location will they be carried out? The Meals on Wheels Coordinator receives referrals and makes determination of eligibility. Kelsey's Café caters the meals and delivers them to Orange Congregations in Mission. Meals are packed into insulated route bags with accompanying direction notebooks. About 100 volunteers (some drive weekly, some substitute as needed) pick up the meals and deliver them to the people on their route. Due to food safety and volunteer time and gasoline, the routes are arranged to only take about one hour for delivery. In some cases, there are areas of the very northern parts of the county our program is unable to reach at this time. 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. Meals are delivered Monday through Friday, between 10:30 and 12:00. During winter storms, when the Orange County Schools are closed due to road conditions, our program does not deliver. Prior to anticipated storms, an additional meal of non-perishable items is sent with the understanding that no meal will be delivered if roads are dangerous. 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: Meals on Wheels receives referrals about possible recipients from Adult Services social workers. • Orange County Department on Aging: Meals on Wheels receives referrals about possible recipients. Likewise, the Meals on Wheels Coordinator makes referrals to the Department on Aging when recipients seem to be in need of other services or there are health or safety concerns. • Various home health agencies: social workers, nurses and aides make referrals for clients they feel would be good candidates for Meals on Wheels. • Area Congregations: Members of area congregations volunteer for Meals on Wheels as well as refer people who may need home-delivered meals. • Orange County Employees, PHE, Sports Endeavors: Employees give up a lunch hour to deliver Meals on Wheels. Main Application 5/25/2016 9:29:51 AM P of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION • Meals on Wheels Association of America: OCIM's Meals on Wheels program is a member of the national organization which provides information, training, and networking opportunities. "Mayors for Meals" is an event sponsored through MOWAA. This annual event involves mayors from local communities in the delivery of meals on the third Wednesday of March. Through this event, local governments become more aware of Meals on Wheels and the needs of the elderly in our community. Hillsborough's mayor, Tom Stevens, has participated in this event for many years. In 2015, Commissioner Renee Price also participated. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If the Meals on Wheels program did not receive funding from Orange County, the program would be unable to continue as it currently exists. Without the Orange County funds, so few meals would be able to be purchased that the program would have to either offer no sliding scale and only be available to people who could afford the full cost or only be available to a very few people. i) Include any other pertinent information. The program demographics give description of the individuals receiving meals. The actual cost per unit reflects numbers of meals delivered. Because the individuals receiving the meals come and go for varying periods of time, there is no way to accurately indicate demographic information for each meal delivered. Program/Project Information j) Complete the Target Population and Program Beneficiary Demographics Chart k) Complete the Schedule of Positions Chart for Program Staff I) Disclosure of Potential Conflicts of Interested must be signed m) Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of all data collection tools that will be used to verify achievement of program goals and objectives. Describe who will be responsible for monitoring progress. Information to Complete j.) Target Population Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: x Persons ❑ Households ❑ Units Program: Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 19 20 20 Female 47 50 50 Total 66 70 70 Main Application 5/25/2016 9:29:51 AM .. of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 26 28 28 American Indian or Alaska Native Asian Caucasian 40 42 42 Native Hawaiian or other Pacific Islander Other Total 66 70 70 Of the above, how many Hispanic/Latino 0 Of the above, how many non- Hispanic/Latino 66 70 70 Total 66 70 70 Age 0-5 years 6-18 years 19-50 years 2 2 2 51-61 years 6 7 7 62+ years 58 61 61 Total 66 70 70 Geographic Location Durham City Durham County Carrboro Chapel Hill Chapel Hill Public Housing Residents Orange County 66 70 70 Raleigh Wake County Total 66 70 70 I 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 Main Application 5/25/2016 9:29:51 AM P of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION Total 0 0 0 Main Application 5/25/2016 9:29:51 AM P 10 of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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 9:29:51 AM Pag , 11 of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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 R/H Manager of Client Services 1 .10 46,052 45,007 45,007 R/H Meals on Wheels/Pantry helper .75 .60 12,398.43 14,040 14,040 All others 3.75 0 115,598.56 135,710 135,710 2 R/H MOW volunteers (1,250 hours) .75 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 9:29:51 AM P , 12 of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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 9:29:51 AM P 1 ,1 of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected 2014-2015 2015-2016 2016-2017 Referrals are made and Referrals are made and Referrals are made and the Meals on Wheels the Meals on Wheels the Meals on Wheels Coordinator follows up Coordinator follows up Coordinator follows up with an initial phone call with an initial phone call with an initial phone call and if qualifications are and if qualifications are and if qualifications are met, a home visit is made met, a home visit is made met,a home visit is made Program Activity 1 and meals are initiated. and meals are initiated. and meals are initiated. A total of 73 people will A total of 70 people will A total of 70 people will receive a home-delivered, receive a home-delivered, receive a home-delivered, nutritious meal five days a nutritious meal five days a nutritious meal five days a Program Goal week week week Information is recorded Information is recorded Information is recorded about dates of referral, about dates of referral, about dates of referral, interviews,and starting interviews, and starting interviews, and starting service as well as reasons service as well as reasons service as well as reasons for needing or for needing or for needing or discontinuing Meals on discontinuing Meals on discontinuing Meals on Performance Measures Wheels. Wheels. Wheels. Of the 66 individuals who Of the 70 individuals who Of the 70 individuals who received a home- receive a home-delivered receive a home-delivered delivered meal, 100% of meal, 100% of this fragile meal, 100%of this fragile this fragile population was population will be able to population will be able to able to remain in their remain in their own remain in their own own homes and maintain homes and maintain homes and maintain independence for as long independence for as long independence for as long as safely possible,other as safely possible, other as safely possible, other arrangements were made arrangements are made arrangements are made for their care,or their for their care, or their for their care, or their Program Results condition improved. condition improves. condition improves. Program Activity 2 Program Goal Performance Measures Program Results Program Activity 3 Program Goal Performance Measures Program Results Program Activity 4 Program Goal MarrAMpact0easures 5/25/2016 9:29:51 AM Pogo 15 of 22 Program Results Program Activity 5 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION Main Application 5/25/2016 9:29:51 AM .. 1 6 o of 2 2 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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 9:29:51 AM 0':°' of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program: Orange Congregations in Mission Meals on Wheels Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 4,342 $ 5,000 $ 5,000 0% Agency Generated Revenue(fees) $ 9,523 $ 15,500 $ 15,500 0% Local Government Grants: Orange County $ 17,000 $ 17,000 $ 17,000 0% Town of Chapel Hill 0 Town of Carrboro 0 Other Local: 0 Other Local: 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 19,623 $ 14,500 $ 14,500 0% State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue $ 4,462 $ 5,000 $ 5,000 0% Please list 3 largest Miscellanous sources: Other foundations&grants $ - $ - Total Agency Revenue $ 54 950 $ 57 000 $ 57 000 0% AGENCY EXPENSES Compensation $ 1,112 $ 1,300 $ 1,300 0% Rent&Utilities $ 7,213 $ 5,450 $ 5,450 0% Supplies&Equipment $ 2,923 $ 4,170 $ 4,170 0% Travel&Training $ 252 $ 250 $ 250 0% Other Expenses: $ 50,235 $ 49,927 $ 49,927 0% Please list 3 largest"Other Expenses": Client Assistance $ 26,586.00 Personnel Costs $ 23,639.00 Depreciation $ 10.00 Total Agency Expenses $ 61,735 $ 61,097 $ 61,097 0% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ (6,785)1 $ (4,097)1 $ (4,097)1 0%I Main Application 5/25/2016 9:29:51 AM Pa 1 o of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget Detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Example Program: Credit Counseling Class Cost Elements Cost($) Quantity/Unit of Measure Subtotal ($) Credit Counseling Teacher–in class $25 96 hours (8 hrs/mth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 48 hours (4hrs/mth x 12 mths) $1,200 Credit Counselor—one-on-one $20 120 hours (10 hrs/mth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Meals on Wheels Cost Elements Cost( ) Quantity/Unit of measure Subtotal( ) Personnel 24,751 24,751 Occupancy 7,213 7,213 Food Purchase 3.25 Cost per meal 28,197 Miscellaneous 3,186 3,186 Total 63,347 C.) Cost per Unit (one meal delivered) Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program 61,736 63,347 63,347 Total # of Units 8,175 8,676 8,676 Cost Per Unit 7.55 7.30 7.30 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 9:29:51 AM .. , 1 of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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 9:29:51 AM .. g 20 of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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 $ 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 9:29:51 AM .. 2 1 o of 2 2 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued Provider's Outside Agency Application MAIN APPLICATION Main Application 5/25/2016 9:29:51 AM P ; 22 of 22 DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Orange Congregations in Mission-Meals on Wheels Funding Award: $17,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Meals on Wheels meal purchases 17,000 Program Services For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes below,by June 30,2016. • Home-delivered meal, five days a week to frail,home-bound recipients 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 Number of meals delivered to Meals on Wheels recipients 70 recipients DocuSigned by: Ekv.. Sow S. Fd Executive Director 10/27/2016 Certified by: RFF,FnFnfi75AA83 Title: Date: (Provider's Signature) DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E 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