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2016-606-E Finance - OC Disability Awareness Council - Outside Agency Performance Agreement
DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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 OC Disability Awareness Council, a not-for-profit corporation, located at 503 W. Franklin Street Room 113, Chapel Hill,NC 27516("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 OC Disability Awareness Council 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 7000. 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 $1,750. 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. (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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. (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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. (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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 OC Disability Awareness Council 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: (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 County: Finance&Administrative Services Provider: OC Disability Awareness Council Orange County 503 W. Franklin Street Room 113 Post Office Box 8181 Chapel Hill,NC 27516 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For an I. . , 1Jaif of the Provider 1104eg Al M ttt,S 10/26/2016 .......; _6OEBA237s15B... Date c5,,,For and Orange County Government 6kbut- C oolit,Y$(Lt1 10/31/2016 1 9 75a7 ... Bonnie Hammer*sley5E, Lounty Manager Date (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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: twtb ltf,S Executive Di rector Certified by: : y G 4 B Title: Date: 10/26/2016 (Provider's Signature) (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency Orange County Disability Awareness Council Date/Time / 1 Complete Y/N Program(s) _Education/Employment, Training, and Technology Services Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. ❑ Applicant Contact Information b. ❑ Project/Program Contact Information c. ❑ Funding Requests Identified d. ❑ Signed Application Cover Page 2. Agency a. ❑ Agency's Years in operation 24 CFR 570.506, Information - b. ❑ Agency's Purpose/Mission 570.507, 570.610; 24 c. ❑ Agency's Types of Services Provided CFR Parts 84 or 85 d. ❑ Agency's Experience e. ❑ Other Pertinent Information 3. Program/ a. ❑ Type of Application and Program Identified 24 CFR 570.200(a), Project b. 570.201-570. 208, ❑ Summary of Program Information - c. ❑ Description of Identified Need 507.503 (for each d. ❑ Description of Population to be Served program/ project for e. ❑ Activity Manager and Location Description which funding f. ❑ Activity Implementation Timeline is requested) g. ❑ Agency Collaboration h. ❑ Describe Impact of Reduced/No Allocation i. ❑ Other Pertinent Information j. ❑ Complete Target Population/Beneficiary Chart k. ❑ Complete Schedule of Positions I. ❑ Signed Conflict of Interest Disclosure m. ❑ Complete Work Statement i o:° DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208, each expenses for the entire program and ALL sources of 507.503 program/ funding. 24 CFR 570.506, project for 570.507, 570.601, which funding a. ❑ Program Budget Worksheet 570.602, 570.607(b), is requested) b. ❑ Program Budget Detail 570.611 24 CFR c. ❑ Cost Per Unit 570.502-570.504, d. ❑ Agency Operating Budget Worksheet 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A- 122; Treasury Circular 1075 5. Supplemental A. ❑ Part A: CDBG & HOME Sections (as B. ❑ Part B: Construction/Rehab applicable) 6. Attachments a. [' Audit: Organizations receiving $300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ❑ NC Solicitation License d. ❑ IRS Federal Tax-Exemption Letter e. ❑ Certificate of Insurance f. ❑ List of Board of Directors 24 CFR Parts 84 or 85 g. ❑ Articles of Incorporation/Bylaws 24 CFR 570.208, h. ❑ Authorization to Request Funds 570.500(c), 570.611 i. ❑ Authorized official designation j. ❑ Solid Waste Program Fee (SWPF) Verification Main Application 5/25/2016 9:25:11 AM P 2 of 2 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Orange County Disability Awareness Council Applicant Organization's Physical Address: 503 West Franklin St., Chapel Hill, NC 27516 Applicant Organization's Mailing Address: 503 West Franklin St., Chapel Hill, NC 27516 Applicant Organization's Web Address: http://triangledac.org/ Executive Director: Timothy Miles Telephone Number: 919.245.4337 E-Mail: ocdac @orangecountync.gov DUNS Number: (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: Education and Training Resources for People with Disabilities Project/Program Primary Contact and Title: Timothy Miles, Director Telephone Number:919-245-4337 E-Mail: ocdac a(�orangecountvnc.gov c) Funding Request Identification Total Project/Program Cost: $30000 Total Amount of Funds Requested: $30000 Proposed Use of Funds Requested (2-3 Line Maximum): Funding for as-needed basic operating expenses, ADA related workshop employment training, human interest projects, resources, supplies, staff training, computer support, travel and printing. Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. *The Participating Jurisdiction reserves the right to fund projects from any funding source, subject to eligibility and funding constraints. ❑ CDBG Non-Construction (CH) $ ❑ Grant ❑ Loan ❑ CDBG Construction (CH) $ ❑ Grant ❑ Loan ❑ HOME CHDO (OC) $ ❑ Grant ❑ Loan ❑ HOME Other(OC) $ ❑ Grant ❑ Loan ® Human Services: ® Carrboro $10000 ® Chapel Hill $10000 ►1 Orange County $10000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: Timoth L. Mile 2016 Executive Dire or Date Signature: L nn M. Shei ds January 20, 2016 Board Chat .- -on _.% /MAW 'ate Main Application +. x%12512016 3:59:43 PM Page 3 of 19 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO ❑ ® a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? ❑ ® b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? ❑ /1 c) Current beneficiaries of the project/program for which funds are requested? ❑ ® d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result in thej nination,of any grant awarded. W ' Signature: ra} , Exe ive Directo ;� n Date / i.. Signature: 1/4/11■. ` Board chairperson- Date / Main Application 2/3/2016 10:23:25 PM Page 13 of 0 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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) 17 years, 2 February 1999 b) Agency's Purpose/Mission The primary mission is to assist in the implementation of the ADA. This is would be through education, training, and other efforts to identify removal of physical, attitudinal, and other barriers to full inclusion and independence for those with disabilities c) Types of Services the Agency Provides The services that TDAC provides are career planning and placement, computer and technology education and training, and professional continuing education workshops. d) Agency's Experience with Similar Programs as the Funding Request These services are provided by trained professionals who have over 25 years of experience in vocational rehabilitation, housing and civil rights education, and the technology industry. e) Other Pertinent Agency Information OCDAC was originally organized in 1970 as a Mayor's Committee in connection with the Governor's Advocacy Council for Persons with Disabilities. Following the passage of the Americans with Disabilities Act in July, 1990, OCDAC was reorganized as a 501(3) (c) nonprofit education organization and commissioned by the Orange County Commissioners, Mayors of Chapel Hill, Carrboro and Hillsborough NC. Main Application 5/25/2016 9:25:11 AM P of 20 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Orange County Disability Awareness Council As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: ® Human Services (Main Application Only) ❑ 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 X X X X Health and Nutrition Job Training X X X X Sports and Arts Activities Pre-School Activities After-School Activities X Mentoring Transportation X X X X Housing X X X X Other: Technology Training & Referrals X X X X Program/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b) Summarize the program services proposed and how the program will address the chosen Town/County priority? • Workshop(s) on disaster preparedness in association with OC EMS, The Orange Sheriff's Office and Social Services. • To some extent, collaborative efforts with NC Fair Housing Project and the Orange County Land-trust to address homeownership to cut down homelessness of people with disabilities. • Computer programs. The computer and assistive technology classes educate Main Application 5/25/2016 9:25:11 AM P 6 of 20 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION citizens about technology which is can be used in the home and on the job • All the Triangle Disability Awareness Council (OCDAC) provides job counseling and training will require collaboration with OC NC Works partner agencies in client's job readiness development, e.g. voice over IPad, speech imput/output. • OCDAC provides volunteer opportunities for members of A Helping Hand, UNC Service Groups which offers work related and/or services learning to junior and seniors in the medical track. Many of the clients they work with who have become share the past work vocation and current disability related experiences. 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 concept of fostering self-sufficiency among persons with disabilities, and fullfill the County and Tri-city government priorities... e.g. affordable/accessible housing, unemployment, accessible and safe living. The Triangle Disability Awareness Council (TDAC) expects to further develop its existing programs, and that will enable more clients to get food delivered the same day delivery, technology training to find gainful employment, city/county ADA related facility assessments, etc. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. • We're serving everyone in the Chapel/Carrboro/Orange County region. TDAC will identify its beneficiaries through the use of social media and our partner agency connections. e) Who specifically will carry out the activities and in what location will they be carried out? • Trained professionals with over 25 years of experience will carry out the activities of TDAC and these events and activities will be held at city/county funded sites. 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. • These activities in coordination with ongoing job education and career training are typically held over a ten month period extending from the end of January until the beginning of December. These programs and activities are held typically held two times per month. In varying degrees of capacity our services are being provided everyday whether that is through personal interaction or electronically. 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. • The Orange County Disability Awareness Council training programs are being developed and implemented with the collaboration of : - Teaming 4Technologies, the United Way, - NC ADA Network, - UNC Apples Interns, High School Service Learning, UNC PA Interns - Various Orange County Offices, OC Libraries, Adult Social Services, etc. - NC Central Food Bank - OC Senior Centers - S.H.I.P. - Triangle Transit, and area transit agencies Main Application 5/25/2016 9:25:11 AM 0':°' of 20 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION - Various Chapel Hill, Carrboro, offices, - Volunteer Center of Durham We invite any other social agencies that desire training or consulting concerning implementation of the ADA and customer services to people with disabilities. We publish a bi annual newsletter and post all events in print and electronic media to the OCDAC website. www.triangledac.org is a major social media source, linking us to organizations such as the NC Housing Coalition and New Hope Project, OPC Mental Health, NC Central Food Bank and Triangle Transit. We have undertaken collaborative projects in housing for persons with disabilities with Housing and Human Rights and the Center for Economic Justice in Raleigh. We have an ongoing collaborative relationship with UNC Apples, A Helping Hand and Chapel Hill High School - Service Learning and the NC Works Center. We have and plan to expand the use of volunteer UNC-Chapel Hill students and hopefully students from other area colleges. We are also continuing to work on developing a cooperative program with North Carolina Services for the Blind. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. • Services for people will low to no income would be charged for the services that TDAC provides and many people would go without. Workload for our partner agencies would increase and general knowledge and understanding about social services would be diminished. TDAC provides necessary resources to its clients that would otherwise not be provided the assistance that they need. i) Include any other pertinent information. • It is crucial with the increase of requests for immediate housing to avoid homelessness by people with disabilities; that we are funded for paid half-time staff. Note: the cost for services and/or rental is $500.00 to 1,500 e.g. assistive listening devices, interpreters. Program/Project Information j) Complete the Target Population and Program Beneficiary Demographics Chart k) Complete the Schedule of Positions Chart for Program Staff I) Disclosure of Potential Conflicts of Interested must be signed m) Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of all data collection tools that will be used to verify achievement of program goals and objectives. Describe who will be responsible for monitoring progress. Information to Complete j.) Target Population Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: ❑ Persons ❑ Households ❑ Units Main Application 5/25/2016 9:25:11 AM Pag of 20 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program: Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 175 180 180 Female 325 335 335 Total 500 515 515 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 300 300 300 American Indian or Alaska Native Asian Caucasian 195 195 195 Native Hawaiian or other Pacific Islander Other 5 5 5 Total 0 0 0 Of the above, how many Hispanic/Latino 5 5 5 Of the above, how many non- Hispanic/Latino Total 500 500 800 Age 0-5 years 6-18 years 50 50 50 19-50 years 325 325 325 51-61 years 125 125 125 62+ years Total 0 0 0 Geographic Location Durham City Durham County Carrboro Chapel Hill 250 250 250 Chapel Hill Public Housing Residents 150 150 150 Orange County 50 50 50 Raleigh Wake County Total 450 450 450 I Income Level —See following chart (Omit for HS) Main Application 5/25/2016 9:25:11 AM P of 2 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION < 30%Area Median Income 31-50% Area Median Income 51-80% Area Median Income > 80%Area Median Income Total 0 0 0 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total 0 0 0 Main Application 5/25/2016 9:25:11 AM Pa I 0 of 2 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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 9:25:11 AM P 0 1 0120 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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 % Projecte (R) *= Position FTE** Program Actual Estimated d 2016- %Total Retirement Vacant Staff+ 2014-15 2015-16 17 Budget Plan (H) Health Plan Operating Officer .5 50 1500 1500 12000 40 N/A Finance Officer .3 15 500 500 4000 13.33 N/A Technology Officer .3 15 500 500 4000 13.33 N/A Administration .3 15 500 500 4000 13.33 N/A Events Coordinator .05 5 volunteer volunteer volunteer N/A N/A 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 1960 Main Application 5/25/2016 9:25:11 AM P , 12 of 2 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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. Emergency preparedness Program Goal 75 75 75 Performance Measures 75 75 Program Results 75 75 75 Affordable housing Program Goal 15 15 75 Performance Measures 15 15 Program Results 15 15 75 Computer classes Program Goal N/A 20 20 Performance Measures N/A 20 Program Results N/A 15 20 Main Application 5/25/2016 9:25:11 AM P 1 ,1 of 20 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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. This budget includes Salaries for the half time positions of Program Director and Administrative/Bookkeeping support. Main Application 5/25/2016 9:25:11 AM Pag 15 of 2 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION Budget Item Budget Amount Personnel -Salaries 24,000 Transportation (Fuel,travel,etc.) 750 Program Supplies 1,750 Outreach (Advertising, printing,etc.) 1,000 Insurance 2,200 Postage 300 Program Total $30,000 Main Application 5/25/2016 9:25:11 AM .. ; 16 of 20 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program: Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations 0 Agency Generated Revenue(fees) 0 Local Government Grants: Orange County $ 4,000 $ 4,000 $ 10,000 150% Town of Chapel Hill $ 3,500 $ 3,500 $ 10,000 186% Town of Carrboro $ 2,500 $ 2,500 $ 10,000 300% Other Local: Hillsborough(discontinued) $ 400 $ - $ - 0 Other Local: ADA Project $ 650 $ 650 $ 650 0% Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way 0 State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: Total Agency Revenue $ 11,050 $ 10,650 $ 30,650 188% AGENCY EXPENSES Compensation $ 3,000 $ 3,000 $ 24,000 700% Rent&Utilities $ 2,000 $ 2,000 $ 2,000 0% Supplies&Equipment $ 3,000 $ 3,000 $ 2,000 -33% Travel&Training $ 1,500 $ 1,500 $ 1,000 -33% Other Expenses: $ 1,500 $ 1,500 $ 1,000 -33% Please list 3 largest"Other Expenses": Total Agency Expenses $ 11,000 $ 11,000 $ 30,000 173% (SURPLUS/(DEFICIT)FOR PERIOD: I $ 50 I $ (350) $ 650] 286J L Main Application 5/25/2016 9:25:11 AM Pa g I 7 of 2 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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: Cost Elements Cost( ) Qua rtity/Unit of measure Subtotal(S.) %2 Time Program Director 12,000 12,000 1/2 Time Administrative/Booking Support 12,000 12,000 Program Supplies (Paper, pens, meeting 1,750 1,750 supplies, etc) Printing brochures, flyers, program badges 1,000 1,000 Company Insurance 2,200 2,200 Postage : brochure/flyer mailings 300 300 Travel to and from meetings; Seminars 750 750 Total 30,000 C.) Cost per Unit Actual 2 014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program Total # of Units Cost Per Unit 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 9:25:11 AM .. of 20 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 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? July 1, 2015 through June 30, 2016. 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 9:25:11 AM .. g of 20 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 t A - continued Provider's Outside Agency Application MAIN APPLICATION OCDAC Operating Budget Expenses Salaries 24000 Office Supplies 1750 Printing 1000 Insurance 2200 Postage 300 Travel 750 Total Expenses 30000 Revenue Grants Orange County 3,500 Town of Chapel Hill 1,000 Town of Carrboro 2,500 Town of Hillsboro 400 ADA Project 650 Total Revenue Grants 8050 Revenue Workshops 4000 Revenue Donations 500 Total Revenue 12,550 Main Application 5/25/2016 9:25:11 AM 0 I:° 20 of 2 DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: OC Disability Awareness Council Funding Award: $7,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Program Support Supplies—Human Interests Projects, Supplies, Staff Training,Computer 7,000 Support,Travel and Printing. 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. • ADA training workshops — Program addresses challenges that persons with disabilities face in pedestrian safety and community travel transition preparedness. • Emergency Preparedness — Provide educational materials, lectures and safety kits to raise awareness about common safety risks. • Affordable Housing — The expectationi is prospective tenants will have the necessary content information and communications tools to readily identify housing discrimination and providers will have a clear sense of any deficiencies in their processes. • Computer class for visually imparied — Classes wil provide information and trianing to area students with disabilities who are or soon will be entering high or higher education. 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 Emergency Preparedness 75 residents Affordable Housing 75 residents Computer Classes 20 residents DocuSigned by: EtitklegUIitt-S Executive Di rector 10/26/2016 Certified by: Title: Date: (Provider's Signature) DocuSign Envelope ID: ED6C5D54-7108-4169-9541-C2FDA3EC8CA6 04ORANGCOU1 N.011111.77" I ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)10/20/2016 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 NAME: BB&T Insurance Services, Inc. PHONE 888 743-2217 FAX 8888279861 (A/C,No,Ext): (A/C,No): 414 Gallimore Dairy Road E-MAIL ADDRESS: Suite F INSURER(S)AFFORDING COVERAGE NAIL# Greensboro, NC 27409 INSURER A:Alliance of Nonprofits Ins RRG 10023 INSURED INSURER B: Orange County Disability INSURER C: Awareness Council INSURER D: 503 West Franklin St#113 INSURER E: Chapel Hill, NC 27516 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. LTR L POLICY EFF POLICY EXP TYPE OF INSURANCE SR WVD POLICY NUMBER N LIMITS (MM/DDIYYYY) (MM/DDIYYYY) A X COMMERCIAL GENERAL LIABILITY BINDER13297729 09/14/2016 09/14/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO $500,000 MED EXP(Any one person) $20,000 PERSONAL&ADV INJURY $1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO- POLICY JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION 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 Directors & BINDER13297748 09/14/2016 09/14/2017 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Miscellaneous Coverage-Directors and Officers-Pol.#BINDER13297748 Directors and Officers Limit#1: 1,000,000 Limit#2: 1,000,000 CERTIFICATE HOLDER CANCELLATION Orange County Government SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 S.Cameron Street ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE awl .S1,94F -+u ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S17002520/M17002518 5WS