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2016-603-E Finance - Human Rights Center of Chapel Hill & Carrboro - Outside Agency Performance Agreement
DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 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 Human Rights Center of Chapel Hill & Carrboro, a not-for-profit corporation, located at 115 West Main Street, Suite#2G, Carrboro,NC 27510 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Human Rights Center of Chapel Hill& Carrboro 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 2000. 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 $ 500. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Human Rights Center of Chapel Hill&Carrboro) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 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. (Human Rights Center of Chapel Hill&Carrboro) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 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. (Human Rights Center of Chapel Hill&Carrboro) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 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 Human Rights Center of Chapel Hill& Carrboro 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: (Human Rights Center of Chapel Hill&Carrboro) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 County: Finance&Administrative Services Provider: Human Rights Center of Chapel Orange County Hill& Carrboro Post Office Box 8181 115 West Main Street, Suite#2G Hillsborough,NC 27278 Carrboro,NC 27510 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 an ). htf of the Provider AI Sbin hilt-5 10/28/2016 5FA3FOQfiF)RR84RC Date For and re w4f f,Orange County Government tka"m rstui 10/31/2016 Q37991 B755E177... Bonnie Hammersley, County Manager Date (Human Rights Center of Chapel Hill&Carrboro) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 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: WS & t,S Certified by: 5Fa3FOA60R884RC Title: Executive Di rector Date: 10/28/2016 (Provider's Signature) (Human Rights Center of Chapel Hill&Carrboro) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Rece v d By Agency: Chapel Hill and Carrboro Human Rights Center e t 'uai ` — 1 Complete t 'V/IN Program: Immigrant and Refugee Community Partnership 1. Cover Page a. 0Applicant Contact Information b. 0 Project/Program Contact Information c. 0 Funding Requests Identified d. 0 Signed Application Cover Page 2. Agency a. 0 Agency's Years in operation 24 CFR 570.506, Information - b. 0 Agency's Purpose/Mission 570.507, 570.610; 24 c. 0 Agency's Types of Services Provided CFR Parts 84 or 85 d. 0 Agency's Experience e. 0 Other Pertinent Information 3. Program/ a. 0 Type of Application and Program Identified 24 CFR 570.200(a), Project b. 0 Summary of Program 570.201-570. 208, Information - c. 0 Description of Identified Need 507.503 (for each d. 0 Description of Population to be Served program/ project for e. 0 Activity Manager and Location Description which funding f. Activity Implementation Timeline is requested) g. 0 Agency Collaboration h. 0 Describe Impact of Reduced/No Allocation i. 0 Other Pertinent Information j. 0 Complete Target Population/Beneficiary Chart k. 0 Complete Schedule of Positions I. 0 Signed Conflict of Interest Disclosure m. 0 Complete Work Statement 1 I II':' c DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency 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. 0 Program Budget Worksheet 570.602, 570.607(b), is requested) b. 0 Program Budget Detail 570.611 c. 0 Cost Per Unit 24 CFR 570.502-570.504, d. 0 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. 0 Part A: CDBG & HOME Sections (as B. 0 Part B: Construction/Rehab applicable) 6. Attachments a. 0 Audit: Organizations receiving $300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. 0 IRS Federal Form 990 c. 0 NC Solicitation License d. 0 IRS Federal Tax-Exemption Letter e. 0 Certificate of Insurance f. 0 List of Board of Directors g_ 0 Articles of Incorporation/Bylaws 24 CFR Parts 84 or 85 h. 0 Authorization to Request Funds i. 0 Authorized official designation 24 CFR 570.208, 570.500(c), 570.611 L 0 Solid Waste Program Fee (SWPF) Verification DocuSign Envelope ID:D2CB2439-4B3B-42E7-A090-286FDDD6E948 - continued Provider's Outside Agency Application 1. COVER, PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Chapel Hill - Carrboro Human Rights Cenler Applicant Organization's Physical Address. 115 W Main St Carrboro NC 27510 Applicant Organizations Mailing Address: 115W Main St, Carrboro NC 27510 Applicant Organization's Web Address: rittpl/www.ircpnc,ora/ Executive Director: KeyinLNQQnan Telephone Number: 019) 295-0570 E-Mail: knoonanPirconc,org DUNS Number, (Dun & Bradstreet, Inc, provides 0-iis number al no charge, at it is required for Federal funding recipients 11). prqjggliPrnirpm_gpptpst information Project/Program Name: Immigrant and Refugee Community Partnership, Project/Program Primary Contact and Title: Kevin J, Noonan Executive Director Telephone Number (919)-295-0570 E-Mail: knoonanQiropprLo_gr c) Funding Request Identification Total Project/Program Cost: $30,000 Total Amount of Funds Requested: $7,50(,), Proposed Use of Funds Requested (2-3 Line Maximum): To supporiplograrhs,operaleg,„byke tlVd....l7.1E,L.0 a Er9r10 HcILTIOn Rights_cell' 0 kat it:5 irnrnlara..nLand„,f3 et,U1..1Q,P C„PlitElnunitY aNQ r 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,9my funding,source, subject to eligibility and funding constiaints CDBG Non-Construction (CH) $ Grant 0 Loan 0 CDBG Construction (CH) ID Grant I Loan 0 HOME CHDO (CC) I: Grant 0 Loan El HOME Other (OC) [1] Grant Li Loan XiD Human Services, U Carrboro $;3,75,9 D Chapel Hill $1,759 D Orange County $2,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The doe Jfl3 as been,dUTV'authorized by the governing board of the applicant. Signature: Kevin J, Noon Exe6(17rector Date 22 January 2016 Signature:J Rev, Nathan Allan Hollister, Board Chairperson Date 22 January 2016 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application Rev. Nathan Allan Hollister, Board Chairperson Date 22 January 2016 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation: 2009-2016 Date of Incorporation: September 2008 Granted 501(c) status in February 2009 b) Agency's Purpose/Mission: The Chapel Hill-Carrboro Human Rights Center is critically-needed within its community: • To promote intercultural understanding amongst community members, highlighting the recognition of the dignity and fundamental rights of others across the several traditionally-divisive lines, including race, ethnicity, class, nationality, and religion. • To provide resources for the under-served and impoverished members of the community through skill development and opportunity recognition, while simultaneously providing a platform for meaningful community-based intercultural learning for local college students through their volunteer involvement. • To provide opportunities for college students enrolled in University courses related to experiential learning, human rights, immigration, poverty, and inequality to gain first-hand experiences in an applied setting, thereby relating course content to its real-world application. • To interact meaningfully with other community organizations to combat poverty, racism, exclusive practices, abuse of workers and tenants, sexism, xenophobia, and homophobia in the broader communities of Chapel Hill and Carrboro. • To engage in activities related to the aforementioned mission and vision of the organization, provided that the organization shall not engage in any activities or pursue any purposes which are not permitted by a Corporation exempt from United States federal income tax under section 501(c)(3) of the U.S. Internal Revenue Code as the same now exists or as it may hereafter be amended. The primary focus of our work is with people who are immigrants and refugees so we added the word Immigrant to our central program area: Refugee Community Partnership (RCP), to better reflect our work. Under the auspices of the Human Rights Center we will be primarily known as the Immigrant & Refugee Community Partnership (IRCP). c) Types of Services the Agency Provides Bridge Builders / After School Program: Bridge Builders (BB) is a Mentoring and Advocacy volunteer program that matches a volunteer or a pair of volunteers to families who are refugees. Volunteers help refugee families through the arduous process of adjusting to life in the United States. Our volunteers are trained to serve under a family mentorship model. Together the volunteer and family define the role of the volunteer. Visits generally occur after school. The volunteer receives guidance from the BB supervisors. DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application The structure of Bridge Builders allows a volunteer to connect with the families by assisting them with everyday life situations. A visit generally lasts an hour to two hours. A weekly visit might consist of helping the children with their homework and parents with their English for half an hour, and then teaching the family how to fill out a particular governmental form or cooking and playing games. Volunteer visits need not be confined to once a week. Outings are often planned, though, by no means, required. Due to the differences of each individual and every pairing, we find it difficult to specifically define "successful relationship" in the Bridge Builder Program. However, what has been proven through evaluation and observation is that, by simply showing up every week, there is a great deal of mutual appreciation and positive feelings. • Youth Empowerment and Education: We believe in the ability of our youth to become community leaders. Through social events and programs offered in partnership with other groups, we encourage leadership development by fostering the empowerment of refugee youth and young adults. We collaborate with organizations, school systems, and teachers to pool resources and develop literacy-focused programs addressing the academic needs of refugee families. Currently, we provide a comprehensive family literacy program at the South Estes Family Resource Center. • Food for the Family: Food insecurity is a serious issue for lower income families who live in the 15-501/54 corridor west of Carrboro, the main area that the HRC serves. Many families who attend the food distribution come not only for themselves, but also to collect vegetables for neighbors and friends. Diversity of diets is an issue for the community, as having a low budget makes it much more difficult to access healthy foods, including fruits and vegetables. The children of the communities we most directly impact have proven especially vulnerable to food insecurity, as students of Mary Scroggs Elementary (the elementary school of many of our tutees) reported that in 2012, 33% of the lunches provided were free or reduced in price. • Working in partnership with Farmer FoodShare the program is a weekly food distribution and solidarity program. Participant-leaders help us distribute hundreds of pounds of fresh produce from the local Farmer's Market to families experiencing food insecurity. Regular participation from 30+ families, which represents an estimated 120+ individuals, of which the vast majority are women of color (recently immigrants or refugees). • English as The Second Language: The mission of the English as a Second Language (ESL) classes is to help ease the transition of recent immigrants to the United States through student interaction with a UNC Campus Y committee called: Linking Immigrants to New Communities (LINC) which provides ESL training and an enhanced level of community awareness. LINC ESL is our longest running program. It provides highly customized one-on-one ESL training to students at all levels; an ideal option for ESL students seeking additional and flexible assistance. LINC ESL has served more than one hundred of our new immigrant neighbors over the years (many of whom attributes their citizenship exam performance to this program). • Through conversations with UNC students, community members gain a proficiency in the language that enables them to seek additional employment opportunities, DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application communicate with fellow citizens freely, and take a more active part in the education of their children. Although Spanish-speakers make up the majority of students in the LINC ESL classes, our program includes people from all over the world, including a growing number of Burmese refugees who live in Chapel Hill and Carrboro. • Tech and Jobs Collaborative: Can you imagine a week without your smart-phone or tablet or laptop? There are segments of our society who has extremely limited access to basic digital literacy (and job access by extension) which we seek to address through a social justice lens. We have worked with low-income neighborhood leaders to design a customized curriculum that is culturally appropriate and accessible. We have partnered with Kramden Institute to offer free computers for our regular participants. Until now, more than 50 individuals have benefited from this collaboration. d) Agency's Experience with Similar Programs as the Funding Request Bonner Leaders Program, UNC: The program has assigned six work-study award recipients to assist with program coordination and tutoring efforts. • APPLES Service Learning Program, UNC: We have partnered with APPLES to provide UNC students in experiential education courses as tutors. • Linking Immigrants to New Communities: (LINC), UNC: LINC coordinates English as a Second Language courses (taken by many parents of afterschool students) that directly impact the ability of the parents to assist their children academically. • Snak Chef/TABLE: TABLE is a nonprofit food distribution program in Carrboro that provides the children with bags of fresh groceries every week. Also, every other week, a group from TABLE and have a "Snak Chef" program with the kids, in which they bring the supplies and help the kids make a delicious and healthy snack. • El Centro Hispano: We are looking forward to forging new relationships with El Centro this semester, as we are temporarily going to be hosting our ESL classes at their center. • The University of North Carolina at Chapel Hill: Most of our volunteers come from UNC-Chapel Hill, as well as many of our past funds and resources. • Campus Y, the Center for Social Justice at UNC-Chapel Hill: The Campus Y also provides many of the volunteers, funds, and resources for the ESL classes. • Farmer Foodshare, Saturday Food Distribution since 2011: The HRC partners with the Farmer Foodshare Donation Station at the Carrboro Farmers Market to source locally grown fresh produce into our community. HRC volunteers arrive before the end of the market and assist Farmer Foodshare volunteers in end of market collection and packing. We then facilitate our own volunteer transportation for the food from market to community distribution. • TABLE, Kid's backpacks since 2011: The HRC previously partnered with TABLE to distribute backpacks of food to our tutoring program. e) Other Pertinent Agency Information HRC's Executive Director, who did an excellent job enhancing the focus of the organization to include people who are Immigrants and Refugees, left to enroll in medical school. HRC recently hired a new Executive Director who not only has experience working with people who are Immigrants and Refugees but has years of experience working with people who are homeless. DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Chapel Hill- Carrboro Human Rights Center. Immigrant and Refugee Community Partners 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: Disabled Public Housing Program Category Youth Adult Elderly (not elderly) Neighborhoods/Resident s Education X X X Health and Nutrition X X X Job Training X X X Sports and Arts Activities Pre-School Activities After-School Activities Mentoring Transportation Housing Other: Please specify Program/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application b) Summarize the program services proposed and how the program will address the chosen Town/County priority? Food Empowerment: Food insecurity is a serious issue for lower income families who live in the 15-501/54 corridor south and west of Carrboro, the main area that the HRC serves. Many families who participate in our food distribution program come not only for themselves, but also to collect vegetables for neighbors and friends. Diversity of diets is an issue for the community, as having a low budget makes it much more difficult to access healthy foods, including fruits and vegetables. Stated Program Activities Anticipated Results Evaluation Program Method Goals Increase access Saturday food We expect 25% more Farmer Foodshare to healthy local distribution and the people will receive collected data on produce from number of community healthy local produce in the amount and an initial 20 gatherings. the new year. client satisfaction families to 25 with distribution methods. Increase Bi-weekly potluck Establish bi-weekly Collect attendance solidarity among gatherings of families gatherings of at least 15 data.- program families from various participants. ethnic groups, to share food. English as a Second Language Classes: The mission of the English as a Second Language classes is to help ease the transition of immigrants to the United States through interactions with volunteers and through an enhanced level of community awareness. Furthermore, we observe that a new generation of bilingual children is being raised within our immigrant communities. Bilingual children often must act as translators for their families. We want to empower adults and older members of the community by equipping them with tools that can sustain their language development. Through conversations with volunteers, community members gain a proficiency in the language that enables them to seek additional employment opportunities, communicate with fellow citizens freely, and take a more active part in the education of their children. The majority of students in the ESL classes have limited English proficiency. Our program includes people from all over the world, including a growing number of Burmese refugees who live in Chapel Hill and Carrboro. DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application Stated Program Activities Anticipated Results Evaluation Program Goals for FY 14-15 Method Maintain and Tutors will work to form We will forging new Program enrollment increase student positive relationships. relationships with students will be documented enrollment to 8-10 Students,who feel in the community thereby through log-in sheets. students in the ESL comfortable with their increasing attendance to Program tutors, stay in the program 8-10 students as the and a high retention rate is notoriety of the tutors and reached. the program's quality. Increase the Tutors and students utilize We anticipate that our The tutors in charge participants' worksheets and pedagogical methods of will evaluate the English language one-on-one conversation active learning will fluency of the students' proficiency to increase the students' improve the English conversations. level of English language proficiency of proficiency. each student throughout the semester to 80%. Increase the ease of Tutors and students work We anticipate that the The tutors will speak integration into together on issues that the students who sense an with students and social and students discuss.Tutors increased ease of transition evaluate whether there professional help students with resume into the social and has been a change in environment building,practice for the professional world will the perceived ease in citizenship test and more, increase to 70%. their social and in order to ease their professional lives due transition into the social to their grasp of and professional world. English. Bridge Builders: The purpose of Bridge Builders is to connect,partner, and collaborate with families who are refugees in the area to help them transition into life in America. The structure of Bridge Builders allows a volunteer to connect with families who are refugees by assisting them with everyday life situations. Families in our Bridge Builder program also needed a lot of ESL tutoring and parents often needed help navigating the community with things such as health care and the school system. This also helps us build stronger relationships with each of our families. We have approximately 50 families, or 250 people, who are refugees in the program. Approximately 37 of them, 185 people, live in Carrboro and about 13 families, or 65 people, live in Chapel Hill. DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application Stated Program Activities Anticipated Results for Evaluation Program FY 16-17 Method Goals To support In addition to weekly We will be able to create Number of resolved adjustment to visits with volunteers, a steady community of discrepancies. life in the US / we will utilize both individuals to help uplift Number of students uplift human social media and and support families in assisted by student rights/and to traditional transition with difficult volunteers with their homework. resist work communication to alert situations exploitation or the community about Monitoring student discrimination issues of which they grades and test scores. in housing should be aware. Tech and Jobs Collaborative: The purpose of this program is to reach segments of our society who have extremely limited access to basic digital literacy (and job access by extension). We seek to address through a social justice lens. We have worked with low-income neighborhood leaders to design a customized curriculum that is culturally appropriate and accessible. We have partnered with Kramden Institute to offer free computers for our regular participants. Until now, more than 50 individuals have benefited from this collaboration. Stated Program Activities Anticipated Results Evaluation Program Goals for FY 14-15 Method Example: 80%of Counselor meets with Out of 100 students School records were after-school students, as the first participating in the checked to verify that attendees will not contact,for students program, 90 remained in students had not been be re-suspended referred for minor good standing with the suspended infractions. school system. 90%result (above goal) Enroll 10-12 Tutors will work with the 10-12 students will not Program enrollment students in the same students for the only learn how to setup and will be documented weekly Tech Jobs duration of the program to use a computer but will be through log-in sheets. program teach them how to setup able to navigate the web for and operate a computer. online job searches. They will also help them Students who complete the navigate the web.. program will be given a desktop computer. DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency 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. Each of our programs seeks to assist people to improve the quality of their lives and of their living conditions. Where possible we seek to support people who face discrimination in the workplace or in housing. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. The population to be served are low-income residents of Chapel Hill, Carrboro, and Orange County. Those most benefiting from our program are immigrants and refugees from all over the world. Beneficiaries are identified through word of mouth and promotional materials from our agency. e) Who specifically will carry out the activities and in what location will they be carried out? The food distribution takes place at the weekly farmer's market and is carried out by volunteers in collaboration with Farmer Food Share and HRC volunteers drawn from the recipient community. The ESL class, also known as LINC (Linking Immigrants to New Communities), meets every Tuesday and Thursday from 6-7pm at Frank Porter Graham Elementary school in Chapel Hill. HRC student volunteers provide one on one tutoring for people who are refugees and immigrants in the Chapel Hill and Carborro area. Bridge Builders mentoring and tutoring takes place at the home of the families who are a part of our program and are carried out by volunteers and is coordinated by Andrea Eisen. 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 activities will be carried out over a period of twelve months beginning on July 1st, 2016. The programs are ongoing, all happening at least once per week. LINC ESL and Tech Jobs do not operate during the summer. g) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. • We collaborate with Farmer Food Share to distribute nutritious food to area residents each week. HRC volunteers transport food weekly to an area in front of the OWASA building for distribution. • We work with LINC ESL (a campus Y committee at UNC) to provide ESL training Student volunteers meet at the Frank Porter Graham Elementary School to provide ESL. DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application • We collaborate with student volunteers to provide mentoring and after school tutoring to families who are struggling to adjust to life in the United States. • We utilize student volunteers to provide weekly Tech and Jobs classes at our offices in Carrboro. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Immigrants and refugees in the community, which receives limited services from other agencies after 90-180 days would be missing an important resource and advocate on their behalf. i) Include any other pertinent information. 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: Food Empowerment Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 4 4 5 Female 30 35 40 Total 34 39 45 Of the females, how many are single-female Head of Households(Omit for Human Services) Ethnicity African-American 3 4 5 American Indian or Alaska Native Asian 21 24 27 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application Caucasian 1 2 2 Native Hawaiian or other Pacific Islander Other 9 13 16 Total 34 39 45 Of the above, how many Hispanic/Latino 9 13 16 Of the above, how many non-Hispanic/Latino 0 0 0 Total 34 39 45 Age 0-5 years 0 0 0 6-18 years 2 2 3 19-50 years 30 34 38 51-61 years 2 3 4 62+years Total 34 39 45 Geographic Location Durham City 0 0 0 Durham County 0 0 0 Carrboro 32 37 43 Chapel Hill 2 2 2 Chapel Hill Public Housing Residents Orange County Raleigh Wake County Total 34 39 45 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 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application Please indicate whether this project/program will serve: x❑ Persons ❑ Households ❑ Units Program: English as a Second Language Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 2 3 4 Female 6 7 8 Total 8 10 12 Of the females, how many are single-female Head of Households(Omit for Human Services) Ethnicity African-American 0 0 0 American Indian or Alaska Native Asian 3 4 5 Caucasian 0 0 0 Native Hawaiian or other Pacific Islander Other 5 6 7 Total 8 10 12 Of the above, how many Hispanic/Latino 5 6 7 Of the above, how many non-Hispanic/Latino 0 0 0 Total 8 10 12 Age 0-5 years 0 0 0 6-18 years 2 2 3 19-50 years 6 8 8 51-61 years 0 0 1 62+years Total 8 10 12 Geographic Location Durham City 0 0 0 Durham County 0 0 0 Carrboro 5 6 7 Chapel Hill 3 4 5 Chapel Hill Public Housing Residents Orange County Raleigh Wake County DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application Total 8 10 12 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 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total Please indicate whether this project/program will serve: x❑ Persons ❑ Households ❑ Units Program: Bridge Builders Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 46 50 56 Female 69 80 84 Total 115 130 140 Of the females, how many are single-female Head of Households(Omit for Human Services) Ethnicity African-American 0 0 0 American Indian or Alaska Native Asian 115 130 140 Caucasian Native Hawaiian or other Pacific Islander Other Total 115 130 140 Of the above, how many Hispanic/Latino 0 0 0 Of the above, how many non-Hispanic/Latino 0 0 0 Total 115 130 140 Age 0-5 years 29 33 36 6-18 years 44 51 56 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application 19-50 years 39 42 46 51-61 years 1 3 2 62+years 1 1 1 Total 115 130 140 Geographic Location Durham City 0 0 0 Durham County 0 0 0 Carrboro 70 75 76 Chapel Hill 45 55 64 Chapel Hill Public Housing Residents Orange County Raleigh Wake County Total 115 130 140 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 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total Please indicate whether this project/program will serve: x❑ Persons ❑ Households ❑ Units Program: Tech &Jobs Program Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 5 7 8 Female 3 5 6 Total 8 12 14 Of the females, how many are single-female Head of Households(Omit for Human Services) Ethnicity DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application African-American 0 0 0 American Indian or Alaska Native Asian 3 4 5 Caucasian 0 0 0 Native Hawaiian or other Pacific Islander Other 5 6 7 Total 8 10 12 Of the above, how many Hispanic/Latino 2 3 3 Of the above, how many non-Hispanic/Latino 0 0 0 Total 8 10 12 Age 0-5 years 0 0 0 6-18 years 2 2 3 19-50 years 6 8 9 51-61 years 0 0 62+years Total 8 10 12 Geographic Location Durham City 0 0 0 Durham County 0 0 0 Carrboro 5 6 7 Chapel Hill 3 4 5 Chapel Hill Public Housing Residents Orange County Raleigh Wake County Total 8 10 12 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 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total CDBG & HOME ONLY- Area Benefit Activities (Infrastructure and Public Facilities) DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application 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.org/portal/datasets/iI/i115/FY2015 IL nc.pdf k.) Schedule of Positions DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). If provided, indicate: Position Titles % Projecte (R) *= Position FTE* Program Actual Estimated d Total Retirement Vacant Staff+ 2014-15 2015-16 2016-17 Budget Plan (H) Health Plan Volunteer $6,050 Coordinator 1.0 100% AmeriCorps $7,200 $0 33% Director .50 100% 0 $12,538 $20,000 66% (H) $2,000 Food Program Coordinator .08 100% $250 $500 $500 2.4% Assistant Director .50 100% Volunteer Volunteer Volunteer 0% $1,375 $1,408 $1,408 4 Work Study .25 each,paid each,paid each,paid Students (ea) .20% by UNC by UNC by UNC 0% Volunteers 2.00 100% Volunteer Volunteer Volunteer 0% 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 I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST DocuSign Envelope ID:D2CB2439-4B3B-42E7-A090-286FDDD6E948 - continued Provider's Outside Agency Application I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: D XE a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? El XLI b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? LI XE c) Current beneficiaries of the project/program for which funds are requested? LI XE-1 d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below, To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of .nundisclo a I I. LPL i i.• 7 rmi tt aw, • -I!. Signature: Kevin J N6ortan, Executive Director Date 22 January 2016 d - Signature: /4' , /4 Rev, Nathan AVan Hollister, Board Chairperson Date 22 January 2016 oocuGNn Envelope|o o2Ce2z1.394e3e42E7,A030-288F0008E9z1.13 [ /\ - continued Provider's Outside Agency Application m.) Work Statement This form is used to document program 3[tividgS, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the pr jected 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 measurable achievement of goals. If goals were not met, please explain. Actual Estimated 2015-2016 Projected Program Activity 1 Program Goal Performance Measures Pro:ram Results Program Activity 2 Program Goal Performance Measures Program Results Program Activity 3 Program Goal Performance Measures Program Results Program Activity,4 Pro:ram Goal Performance Measures Program Program Activity 5 Performance Measures 111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111111 Program Results DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency 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. We regret we are unable to embed Excel budget files into this Word Document. As a result the Excel files will be submitted as attachments 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 $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application Program: Food Empowerment Program Cost Elements Cost($) Quantity/Unit of measure Subtotal($) Personnel $19.23 (1.25 hrs per week x 52 weeks) $1,250 Rent $100 $100/mo. x 12 months $1,200 Supplies& Equipment $27.09 -$27.09 x 12 mo. $325 Travel &Training $21.16 26 potluck solidarity meetings $550 Other Expenses -$1,138 %of the yearly liability Insur. 285 Total $3,610 c.) Cost per Unit Actual 2014-15 Estimated 2015=16 Projected 2016-17 Total Cost of Program $950 $1,250 $3,610 Total # of Units 34 39 45 Cost Per Unit $27.94 $32.05 $80.22 Program: Bridge Builder / After School Program Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Personnel -$19.23 (5 hrs per week x 52 weeks) $5,000 Rent $100 $100/mo. x 12 months $1,200 Supplies& Equipment -$41.66 12 months $500 Travel &Training -$45.83 12 months $550 Other Expenses -$1,138.00 %of the Liability Insurance $285 Total $7,535 d.) Cost per Unit Actual 2014-15 Estimated Projected 2016-17 2015-16 Total Cost of Program $600 $2,685 $7,535 Total # of Units 115 130 140 Cost Per Unit $5.22 $20.65 $53.82 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application Program: English as a Second Language (ESL) Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Personnel $19.23 (1.25 hrs per week x 52 $1,350 weeks) Rent $100 12 months $1,200 Supplies& Equipment -$41.66 12 months. $500 Travel &Training -$8.33 12 months $100 Other Expenses -$1,138 %of the yearly liability Insur. $285 Total $3,435 e.) Cost per Unit Actual 2014-15 Estimated Projected 2016-17 2015=16 Total Cost of Program 600 $2,685 $3,435 Total # of Units 8 10 12 Cost Per Unit $75.00 $268.00 $286.25 Program: Tech & Jobs Program Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Personnel $19.23 (2.5 hrs per wk x 52 weeks) $2,500 Rent $100 12 months $1,200 Supplies& Equipment -$41.66 12 months. $500 Travel &Training -$8.33 12 months $100 Other Expenses -$1,138 %of the yearly liability Insur. $285 Total 4,585 f.) Cost per Unit Actual 2014-15 Estimated Projected 2016-17 2015-16 Total Cost of Program 600 $2,685 $4,585 Total # of Units 8 12 14 Cost Per Unit $75.00 $223.75 $327.50 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application 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). g.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. We regret we are unable to embed Excel budget files into this Word Document. As a result the Excel files will be submitted as attachments DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 t A - continued Provider's Outside Agency Application Section VI. Financial Data Comparative Budget for Entire Agency AGENCY NAME: Human Rights Center of Chapel Hill and Carrboro Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 800 $ 7,500 $ 9,413 26% Agency Generated Revenue (fees) $ - $ - $ - 0 Local Government Grants: Orange County $ - $ 1,000 $ 2,000 100% Town of Chapel Hill $ - $ - $ 2,775 0 Town of Carrboro $ 2,000 $ 2,750 $ 3,750 36% Other Local: --- 0 Other Local: --- 0 Other Local: --- 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government $ - $ - $ - 0 Other Grants:Chapel Hill Youth Forward $ - $ - $ - 0 Other Grants: Federal Work Study(UNC) $ 5,650 $ 5,650 $ 8,950 58% Miscellaneous/Other Revenue $ 6,175 $ 1,500 -76% Please list 3 largest Miscellanous sources: Anonymous Donor $ 7,900.00 Church Fundraising $ 713.00 Tar Heel 10-Miler $ 800.00 Total Agency Revenue $ 8 450 $ 23 075 $ 28 388 23% AGENCY EXPENSES Compensation $ 6,000 $ 16,000 $ 20,000 25% Rent& Utilities $ 900 $ 3,600 $ 4,800 33% Supplies &Equipment $ 900 $ 1,275 $ 1,450 14% Travel &Training $ 650 $ 1,000 $ 1,000 0% Other Expenses: $ - $ 1,200 $ 1,138 -5% Please list 3 largest"Other Expenses": Liability Insurance $ 1,138.00 $ $ - Total Agency Expenses $ 8 450 $ 23 075 $ 28 388 23% SURPLUS/(DEFICIT) FOR PERIOD: $ - I $ - I $ - I 0 DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Human Rights Center of Chapel Hill& Carrboro Program Name: Funding Award: $2,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Programmatic Expenses 2,000 Personnel Expenses associated with ESL 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. • English as Second Language Program: Develop personalized lessons for ESL students of all levels (i.e. beginner, intermediate, advanced levels) and provide one-on-one tutor: student ratio to achieve maximum English language improvement for the participants • End of year ESL Program Celebration: Reflect, share and celebrate the success of the ESL participants with rest of the broader immigrant community 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 Increase and maintain enrollment in the ESL Program 12 students Percentage of participants with improvement of English proficiency 80% Percentage of participants with improved integration and ease at social and/or job 80% environment due to increased English proficiency Maintain at least 3:1 student:teacher ratio 100% DocuSigned by: A iSbin, �GU1f S Executive Di rector 10/28/2016 Certified by: Title: Date: • .•.O1U237341b(.... (Provider s ignature) DocuSign Envelope ID: D2CB2439-4B3B-42E7-A090-286FDDD6E948 CHAPHIL-06 VDECAMP 4C 7RIJ CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `---''' 10/27/2016 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 have ADDITIONAL INSURED provisions or 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 NAME: Summers Thompson Lowry,Inc. PHONE FAX 100 Europa Drive (A/C,No,Ext):(919)968-4472 (A/C,No):(919)942-4221 Suite 571 ao AIL Vicky @STLinsure.com Chapel Hill,NC 27517-2393 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:AmTrust Financial Services INSURED INSURER B: Chapel Hill Carrboro Human Rights Center,Inc. INSURER C P.O.Box 461 INSURER D: Carrboro,NC 27510 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR NPP1005772 08/21/2016 08/21/2017 DAMAGETORENTED X PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ A COMBINED SINGLE LIMIT AU LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY NON-OWNED ONLY PROPERTY DAMAGE (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A General Liability NPP1005772 08/21/2016 08/21/2017 Hired/Non-Owned Auto 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Non-profit organization that tutors K-5 students,distribute food to adult clients,teach technology to adult clients CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Risk Manager THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 9 Y 9 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough,NC 27278 A-{„U�TyHORIZED REPRESENTATIVE ACORD 25(2016/03) M1 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD