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HomeMy WebLinkAbout2016-630-E Finance - Charles House Association - Outside Agency Performance Agreement DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 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 Charles House Association, a not-for-profit corporation, located at 7511 Sunrise Road, Chapel Hill,NC 27514("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 Charles House Association agree as follows: 1. Term of the Agreement. The tenn 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 20000. 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 $5,000. 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. (Charles House Association) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 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. (Charles House Association) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 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. (Charles House Association) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 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 Charles House Association 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: (Charles House Association) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 County: Finance &Administrative Services Provider: Charles House Association Orange County 7511 Sunrise Road Post Office Box 8181 Chapel Hill,NC 27514 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. E P For and :the Provider ea WLV V 11/2/2016 § 5F664BB... Date For an Dti Orange County Government INIA,I/LIt- avoit- stu1 11/4/2016 0637994B755E477... Bonnie Hammersley, County Manager Date (Charles House Association) Orange County Outside Agency Per/onnance Agreement Rev. 8/16 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 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. r---DocuSigned by: ea 5tuxr Executive Director 11/2/2016 Certified b : Title: Date: y cr201133II51-cc4DD... (Provider's Signature) (Charles House Association) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST I FOR OFFICE USE ONLY Received By Agency CHARLES HOUSE ASSOCIATION Date/Time Complete Y/N Program(s) Daytime Eldercare Program Section For CDBG & HOME - Subsection HUD Regulations 1. Cover Page a. 1.1 Applicant Contact Information b. 1411 Project/Program Contact Information c. or Funding Requests Identified d. r 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 CFR Parts 84 or 85 c. 4 Agency's Types of Services Provided d. Agency's Experience e. Other Pertinent Information 3. Program/ a. Type of Application and Program Identified 24 CFR 570.200(a), Project b. I Summary of Program 570.201-570. 208, Information - c. r Description of Identified Need 507.503 (for each d. Description of Population to be Served program/ e. 11 Activity Manager and Location Description project for f. r Activity Implementation Timeline which funding is requested) g. Agency Collaboration h. I 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. 4 Complete Work Statement ilF) age DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 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. RI Program Budget Worksheet 570.602, 570.607(b), is requested) b. I Program Budget Detail 570.611 24 CFR c. 46, Cost Per Unit 570.502-570.504, d. lAgency 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. D Part A: CDBG & HOME Sections (as B. 0 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. It. IRS Federal Form 990 c. ■ NC Solicitation License d. IRS Federal Tax-Exemption Letter e. I Certificate of Insurance f. `CI List of Board of Directors 24 CFR Parts 84 or 85 g. S. Articles of Incorporation/Bylaws 24 CFR 570.208, h. CI Authorization to Request Funds 570.500(c), 570.611 i. L Authorized official designation j. Solid Waste Program Fee (SWPF) Verification Main Application 1/25/2016 11:54:37 AM Page 2 of 21 DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE ; program re�m|resmseparate Xi ti 1 a) Applicant Contact Information Applicant Organization's Legal Name: Charles House çiatio Applicant Organization's Physical Address: 7511 Sunrise Floed, Chapel Hill, NC 27514 Applicant Organization's Mailing Address: 7511 Sunrise Road, Chapel Hill, NC 27514 Applicant Organization's Web Address: .charleshouse.orq Executive Director: Paul Klever Telephone Number: 919-967-7570 E-Mail: pmu|@chor|ashouse.o0Q 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: Charles House-Daytime Eldercare Program Project/Program Primary Contact and Title: Paul K|ove[, Executive Director Telephone Number: Q1S'QO7'75TO E-Mail: pau| nhedeshoUne.o[Q c) Funding Request Identification Total P 'eoVP[nQramCoot $54U.000 Total Amount of Funds Requested: $35.000 Proposed Use of Funds Requested (2-3 Line Maximum): These funds will be used to support Charles House Daytime Eldercare Program at the new Center for Community Eldercare in Chapel Hill. These services support ca re giving families from Orange County and their aging family members, Please check all types, sources, and amounts of funding being requested. You must submit an application package fo i source, *The Participating Jurisdiction reserves the right to fund p ' nhs from any funding source, subject to eligibility and funding constraints. • CDBG Non-Construction (CH) $ 0 Grant El Loan ▪ CDBG Construction (CH) 0 Grant Loan • HOME CHDO (OC) 111 Grant Loan | HOME � / | (�rmnt | | Lo�n �~ ` ' ' �~ ^~ r Human Services: Carrboro $4000 I Chapel Hill $11.000 r Orange County $20.000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: S :>`1/ 2 Executive Director Date Signature: 441444- ��� ���^ � ��' ' ------- ' � Board Chairperson Date K8a|nAnnhoation 1/21/2016 12:22:19 PM Page 3 of 1G DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- 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) Charles House Association was incorporated March/1984. Operations began in June, 1990, with the Charles House daytime eldercare program in a renovated mill house in Carrboro. June,2015, marked the 25 o'uunivemuryo{CbadeuBounm'oucrvioc{oLbcconoouuni1y. b) Agency's Purpose/Mission Charles House Association is a private, nonprofit organization whose mission is threefold: i. Enriching the lives of seniors ii. Supporting families caring for aging b*oni|vouoonbcrm iii. Representing the community's commitment to its elders Charles House focuses on community eldercare services, particularly the Support of caregiving families who are caring for family members facing many of the challenges of aging and later life, such as dementia, including Alzheimer's, frontal-temporal dementia, Lewy Body; Parkinson's, multiple sclerosis, stroke, other neuro-muscular disorders, macular degeneration, ambulation difficulties, c) Types of Services the Agency Provides Charles House Association relocated its primary operations into a larger facility at 7511 Sunrise Road, Chapel Hill, known as the Center for Community Eldercare. Charles House continues to operate the pioneering residential care settings—neighborhood eldercare homes—in the Heritage l-Iills and the Winmore neighborhoods. The Charles House Center for Community Eldercare includes: * Daytime Eldercare Program m Caregiver Orientation, Resources and Education CORE Support Program • The Program in Learning& Service: opportunities for students and interns to be introduced to careers in aging and the positive Charles Flouse approach to working with elders • Agency Administration, Community Outreach, Management of Eldercare Homes For the past three years, Charles House has been co-convener, with Orange County Dept. on Aging and Second Journey, of the Aging-in-Community speaker/discussion series. This initiative has sparked much thought and discussion within the community about the future of senior housing alternatives, through forums, local and nationally known speakers. d) Agency's Experience with Similar Programs as the Funding Request Charles House Association has experienced a steady increase in the number of caregiving families in our communities. With the growing demographics of elders in our state, and particularly in Orange County, the numbers of families with aging/older family members is growing and so are the numbers of people who are experiencing frailty and needing assistance/support. Seventy percent of older Americans who need long-term support services receive this support exclusively from family and friends. Supporting these families in their caregiving journeys is the primary focus and part of the important community mission of Charles House Association. The Daytime Eldereare Program of Charles I louse at the Center for Community Eldercare is highly unique compared to other adult day programs and is a model for our state. The Charles House program has developed a Continuous Engagement Model that supports individuals' functioning, involvement and contributions to the group process at all tim s. Elders with various kinds of cognitive and physical challenges experience executive function loss; the Charles House program individualizes its support of Main Application 1/25/2016 11:54:37 /\M Page 4 of 21 DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- continued Provider's Outside Agency Application MAIN APPLICATION executive functioning and creates au environrrient where participants uce "nonnal," iouou{oawik/thcir experience in the larger world. Furthermore, the group setting of Charles House offers benefits beyond those provided by in-home care agencies. The cost to families for Charles House is half the rates of in-home care agency services. The respite and support provided to family caregivers is enhanced by the quality of engagement their family members receive at Charles I-louse. At Charles House, family caregivers share their expeiience—trials and challenges—with others in the journey of caregiving and learn about services, practices and approaches that can support their caregiving. The Charles House approach of supporting family caregivers and providing high quality engagement for participant family members often means that families continue their caregiving journey at home through the end afire. Family caregivers report improvements in the functioning of their loved ones after enrolling in the Charles House program; these improvements—real and perceivedi are therapeutic for everyone involved in the caregiving household. e) Other Pertinent Agency Information Charles House Association is the leading eldercare services nonprofit agency in our community, establishing innovative approaches for caregiving families and services for elders, particularly as they move into frailty. While the Daytime Eldercare Program is a cost effective alternative for caregiving families, approximately 15'20% of Charles House families receive financial assistance. Charles House maintains an internal Scholarship Fund from individual, charitable donations made to support access to services. Orange County families are eligible for agency purchased days from the Department of Social Services and through the Department on Aging. These agency contracts are limited and reimburse Charles House at less than 50% of the cost. The Outside Agency Funding helps to defray the lost revenue for these Orange County clients. Main Application 1/25/2016 11:54:37 AM Page 5 of 2 1 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 t A- continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Charles House: Daytime Eldercare Program 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: 11 Human Services (Main Application Only) 111 CDBG Non-Construction —(Main Application AND Part A) El CDBG Construction —(Main Application AND Part A AND Part B) 111 HOME CHDO Set-aside —(Main Application AND Part A) El HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Program Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education Health and Nutrition Job Training Sports and Arts Activities Pre-School Activities After-School Activities Mentoring Transportation Housing Other: Please specify Daytime Eldercare Proaram/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: a) Summarize the program services proposed and how the program will address the chosen Town/County priority? The Chapel Hill Human Services Advisory Board has identified this priority: To fund programs aimed at improving health and nutrition of needy residents. Charles House Daytime Eldercare Program provides significant support to the health, nutrition and wellbeing of some of the most frail citizens in our community and supports the health of their family caregivers. Main Application 1/25/2016 11:54:37 AM Page 6 of 21 DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- continued Provider's Outside Agency Application MAIN APPLICATION b) 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 Consolidated Plan appears to refer to the HOME Consortium. However, the population growth statistics for Orange County indicates a doubling of the 65+population by 2030. The implications of this population growth effects many aspects of our community/public life, but in particularly the challenges families lace with the onset of aging disabilities, durueodno and other disorders demanding the care and assistance of others. c) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. IbcI)uy\i/no Eldercare Program at Charles House has enrollees aged from late 50s to 100. The population served also includes their family caregivers. Enrolled families are residents of Chapel Hill, Carrboro, Orange County, Durham County, Chatham County. The challenges these families face stem from dcmuu\iau, including Alzheimer's, Parkinson's, stroke, uonco*unucu|o,disorders, multiple sclerosis,vision loss, ambulation disability, etc. Beneficiaries are identified through community outreach, inter-agency alliances, physician referrals, community publicity and word-of-mouth. d) Who specifically will carry out the activities and in what location will they be carried out? The Daytime Eldercare Program at Charles House is operated at the Center for Community Eldercare at 7511 Sunrise Road, Chapel Hill. The program is carried out by a program team of leaders, facilitators, volunteers and xtodon1u� '[hoCharles House 1ounobnoodcupof people vvdbvarying levels o[experience including people with years of experience working with people with dementia to others who may be new to the arena but who show a high level of affinity, compassion and leadership. The staff includes expertise in social work, recreation therapy, art therapy, communication and approaches for dementia. e) 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 Daytime Eldercare Program operates Monday through Fridays, 7:30 to 5:30. f) Provide a bulleted list of other agencies, if any, with which your agency coordinatgs/cmkUabmratemto accomplish or enhance the Pr jected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. • Orange County: Department on Aging collaboration on various projects, including the Master Aging Plan, the Aging-in-Community series, sharing referrals for aging transitions, long-term care collaborative, contractually serve Orange County families/caregivers. • Orange County: Department of Social Services—collaboration on contractually serving Orange County {mnni|ion/oaro9ivom, as well as with Adult Protective Services and o:Aulato?yoverydu done by DSS. • UNC-Chapel Hill—collaborations with many of the schools and academic departments/programs on opportunities for learning service for students/interns. • UNC Health Care--collaboration on clinical initiatives, volunteers and Charles House leadership • Duke University—collaboration with the Fuqua Business School, Medical School and Family Support Program. • Central Carolina University collaboration with the school of social work. • Durham Technical—collaboration with the occupational therapy assistant program • Watts School of Nursing collaboration on service learning • Chapel Hill Transit E-Z Rider collaboration on transportation • Orange County Animal Shelter—collaboration on community service projects for sheltered animals. Main Application 1/25/2016 11:54:37 AM Page 7 of 21 DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- continued Provider's Outside Agency Application MAIN APPLICATION ° N.C. Botanical Gardens collaboration in horticulture therapy w Chapel Hill Library—collaboration on community service pr jects for children's library • Ackland Art Museum—collaboration on museum visits for dementia. * Chapel Hill Service League collaboration on community service projects for the League's Christmas 1-louse. � IFC's ffomcStart Homeless Shelter collaboration on community service projects, including flower arrangements for the Home Start shelter. � Carol Woods Retirement Community—collaboration on community outreach and service to residents. � Carolina Meadows -w|)aborudoudouugbCu/nliooMeadovvmcononnuoityuAcnoy [uoJioAprogrmnuod service to residents. * Various home health agencies; area assisted living and nursing care facilities collaboration on service coordination, client refelTals, etc. • Various area schools—student groups, including music groups, volunteer at Charles House. p Area civic groups, churches—community outreach, church and group members often volunteer at Charles House. g) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If this funding request were not aw rdcd or if it were reduced, Charles I-louse would be limited in its financial ability to accept the reduced contractual rates from the Departments of Social Services and on Aging. There would be a reduction in the access to Charles House services by families of need. h) Include any other pertinent information. Program/Project Information R Complete the Target Population and Program Beneficiary Demographics Chart j) Complete the Schedule of Positions Chart for Program Staff k) Disclosure of Potential Conflicts of Interested must be signed I) 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: A Persons Households Units Program: Charles House Daytime Eldercare Program Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-10 201847 Gender Male 30 35 40 Female 49 55 60 ' Total 79 90 100 Main Application 1/25/2016 11:54:37 AM Page 8 of 2 1 DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- continued Provider's Outside Agency Application MAIN APPLICATION Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 6 8 11 American Indian or Alaska Native Asian Caucasian 72 79 84 Native Hawaiian or other Pacific |s|. Other 1 3 5 Total 79 90 100 Of the above how many Hispanic/Latino 1 2 3 Of the above how many non- Hispanic/Latino 78 88 97 � Total 79 � 80 100 Age 0-5 years 6-18 years 1111111111.11.=1 19-50 years 51-61 years MIEIII=11M 62+ years 78 88 97 Total 79 90 100 Geographic Location Durham City Durham County 19 22 24 Carrboro 2 4 5 Chapel Hill 36 38 42 Chapel Hill Public Housing Residents Orange County 4 6 7 Raleigh Chatham/Alamance/Wake Counties 18 20 22 Total 79 80 100 Income Level—See following chart (Omit for HS) < 3OY6 Area Median Income 31-50%Area Median Income 51-8OY6 Area Median Income > 80%Area Median Income Total 0 0 0 Special Needs (Omit for HS) Elderly (Over 62) Disebled (not Homeless People with HIVfAids Total 0 0 0 Main Application 1/25/2016 11:54:37 AM Page 9 of 21 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 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.org/portal/datasetsill/ill 5/FY2015 IL nc.pdf Main Application 1/25/2016 11:54:37 AM Page 10 of 21 DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- 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: � ��Toto Position Titles 96 Total (R) Actual Estimated Projected Program ^ = Position FTE** Program ' Retirement 2014'15 2015-15 2016'17 Budget Vacant Staff+ (2016) P|an (H) Health � | Plan ' -- ` -------�- Prog. oV1�z.ornE (MSW,- Rec.Therapy, 2015:3.4,VE 1 Art Tkemp .otc.) 2016:41ns 100% 80000 112000 153000 30% (R)(H) 2014:2.1FTE on1n2.ma Pros. Facilitato z01�x�,TE 100Y4 40000 52000 83000 15% (R H Cook/Food Srv. 0.0FTE 100% 1 27000 27750 28000 5% (R)(H) I Prow. Admin8NSVV 1FTE 10096 ! 0 50000 55000 10% (R)(H) Assoc. Director 1FTE 25% 24330 21200 16000 3% R H Exec. Director 1FTE 20% 27260 22300 23500 4.396 __ Admin. Ams't 1FTE 75% 25500 0 0 0 Volunteers 1.5FTE 1 MI Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • °° Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours =Volunteer FTE 1,960 Main Application 1/75/2016 3:11:08 PM P a g e 11 of 2 1 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 t A- continued Provider's Outside Agency Application MAIN APPLICATION l.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO r a)Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? El 14,, b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? El c) Current beneficiaries of the project/program for which funds are requested? El X1 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 the termination of any grant awarded, /e/71/11, Executive Director Oat Signature: eie4-44- /1-c-i-e744 0.1 0-0 Board Chairperson Date Main Application 1/21/2016 2:00:34 PM Page 1 0 of 1 6 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 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. O Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. SMART Goals o Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. o Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. Main Application 1/25/2016 11:54:37 AM Page 13 of 21 DocuSign Envelope ID:78 e-B256-33o571Ae4687 [ /\- continued Provider's Outside Agency Application MAIN APPLICATION - -- Actual Estimated Projected 2014-2015 2015'2016 2016-2017 The Charles House Daytime Program supports family caregivers by offering respite from the ongoing concerns of Program Activity 1 caring for a loved one and by Same Same supporting the best functioning of their loved ones through participation in the therapeutic program Enrollment in the program allows Program Goal caregiving families to continue their Same Same caregiving as they wish. w 50%of enrolled families in the funding year will have the capacity to Performance continue providing care in the home Same Same Measures and not require,or delay, residential carep|acemenifortheirpaMidpant/ enrollee. At the end of the FY, it is It is being projected that estoimated that 60%of in FY16-17 that 65%of the the families enrolled at families enrolled at the Program Results At the end of the FY, 70%of the the beginning of the FY beginning of the FY will families enrolled at the beginning of will still be engaged in still be engaged in caring the FY were still engaged in caring for caring for their loved ones for their loved ones at their loved ones. with Charles House. Charles House. It is projected that the In the 2015 Caregiver annual Caregiver Survey in Survey, I000%of 20I6 will show a high Program Results In the 2014 Caregiver Survey, 100%of respondent families percentage>85%of respondent families reported reported improved respondent families will improved functioning in their family functioning in their family report improvements in members members functioning. The relationship Charles House maintains with enrolled families is the basis for the collaboration in caring. The daytime program works to support a variety of functioning abilities for Program Activity 2 participants: including self-esteem, Same Same gross and fine motor skills, social skills,verbal skills, ambulation, memory and reminiscence,activities of daily living. Main Application 1/25/2016 11:54:37 AM Page 15 of 21 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 t A- continued Provider's Outside Agency Application MAIN APPLICATION The Charles House program thrives to Program Goal Same Same enhance the functioning and quality of life for participants. Over 50%of families will report in the annual evaluation survey satisfaction with the Charles House program and Performance will report positive effects of the program for their enrolled family Same Same Measures members, such as improvement in their participant/enrollee's behavior, emotional status, physical and/or cognitive functioning. It is projected that the annual Caregiver Survey In the 2015 Caregiver in 2016 will show a high Survey' of percentage,>85%,of Program Results respondent families respondent families will In the 2014 Caregiver Survey, 100%of reported improved report improvement in respondent families reported improved functioning in their family family member functioning in their family members members functioning. Program administration assures that all aspects of the program are in Program Activity 3 compliance with the state rules for annual certification The program strives for a level of Program Goal excellence and maintains standards same same required by the State Division of Aging and Adult Services Charles House Association will Performance continue to surpass the NC Standards same same Measures and maintain state certification to operate as an adult day program. Charles House received Charles House will recertification by the State maintain certification by Program Results Charles House received recertification Division of Aging and the State Division of by the State Division of Aging and Adult Services in July, Aging and Adult Services Adult Services in May,2014 2015 for the new center. in 2016. Main Application 1/25/2016 11:54:37 AM Page 16 of 21 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 t A- continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 1/25/2016 11:54:37 AM Page 17 of 21 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 t A- continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Progran Charles House:Daytime Eldercare Program Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations 0 Agency Generated Revenue (fees) $ 381,700 $ 377,000 $ 535,000 42% Local Government Grants: Orange County $ 15,000 $ 15,000 $ 20,000 33% Town of Chapel Flill $ 9,000 $ 9,000 $ 11,000 22% Town of Carrboro $ 4,000 $ 3,500 $ 4,000 14% Other Local: 0 Other Local: 0 Other Local: 0 t 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 Triangle Comm Fndtn $ 15,000 $ 14,000 $ 15,000 7% Other Grants SECC $ 4,800 $ 5,000 $ 5,000 0% Miscellaneous/Other Revenue $$ $ - Total Agency Revenue $ 429 500 $ 423.500 $ 590 000 39% AGENCY EXPENSES Compensation/Personnel $ 325,000 $ 350,000 $ 410,000 17% Rent Utilities, Insurance, Property Expenses $ 28,250 $ 55,000 $ 89,000 62% Supplies,Equipment Program, Food Srv. $ 30,500 $ 33,000 $ 35,000 6% Administrative Expenses $ 11,900 $ 5,100 $ 7,500 47% Other Expenses: $ 14,775 $ 14,100 $ 23,000 63% Rease list 3 largest"Other Expenses": Depreciation/Amortization $ - $ - Total Agency Expenses $ 410 425 $ 457 200 $ 564 500 23% SURPLUS/(DEFICIT)FOR PERIOD: 1 $ 19,0761 $ (33,700)1 $ 25,500 1 176% Main Application 1/25/2016 11:54:37 AM Page 18 of 21 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 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 $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Charles House: Daytime Eldercare Program Cost Elements Cost($) quantity/unit of measure Subtotal($) Cost elements are those included In the program budget above: Costs included in program budget Personnel Expenses Property Expenses Program Expenses Administrative Expenses Other(Depreciation) Expense Total c..) Cost per Unit: (Unit of Service defined as 1 participant service day at Charles House) Actual 2014.15 Estimated 2015.16 Projected 201647 Total Cost of Program $ 410,425 $ 457,200 $ 564,500 Total # of Units 5195 5315 6500 Cost Per Unit $ 79 $ 86 $ 86 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 1/25/2016 11:54:37 AM Page 19 of 21 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 t A- continued Provider's Outside Agency Application MAIN APPLICATION d.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year What is your agency's fiscal year'? Example: July 1, 2016 through June 30, 2017. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 1/25/2016 11:54:37 AM Page 20 of 21 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 t A- continued Provider's Outside Agency Application MAIN APPLICATION AGENCY NAME: Charles House Association Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2016-16 2016-17 Change Private Donations $ 115,000 $ 110,000 $ 80,000 -27% Agency Generated Revenue(fees) $ 916,500 $ 1,187,000 $ 1,360,000 ME! Local Government Grants: Orange County $ 15 000 $ 16,000 $ 20,000 33% Town of Chapel Hill $ 9,000 $ 9 000 $ 11,000 22% Town of Carrboro $ 4,000 $ 3,500 $ 4,000 14% Other Local: 0 Other Local: Mill1111111MI 1■1111111111111 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way I=.11111101111111 0 State Government 1.111.111111111. 1111111111111111 0 Federal Government 11111111. MIIIIM 0 Other Grants:Triangle Comm.Fndtn, $ 15,000 $ 14,000 $ 15,000 7% Other Grants: $ 20,000 $ 20,000 $ 15,000 -25% Miscellaneous/Other Revenue $ 10,000 II= 0 Please list 3 largest Miscellanaus sources: Cottage Rental $ - $ - $ - Total Agency Revenue 1,104500 $ 1 358 500 1 606 000 11% AGENCY EXPENSES Compensation,Personnel $ 750,000 $ 980,000 $ 1,100,000 12% Rent,Utilities,Insurance,Property $ 90,000 $ 145,000 $ 157,000 MI Supplies,Equipment,Program,Food Srvs $ 65,000 $ 80,000 $ 73,000 111=11 Admin.Expenses(Development,Outreach) $ 113,000 $ 54,000 $ 40 000 -26% Other Expenses: $ 43 000 $ 55,300 $ 61 200 11/o Please list 3 largest"Other Expenses": Depreciation/Amortization $ - $ - $ - Total Agency Expenses 1 061 000 $ 1 314 300 1 431 200 9% SURPLUS/(DEFICIT)FOR PERIOD: is 43,500j$ 44,200 1$ 73,800 67%1 Main Application 1/25/2016 3:18:06 PM Page 21 of 21 DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Charles House Association Funding Award: $20,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel Expenses 20,000 Program Services For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes below,by June 30,2016. • Daytime Program supports family caregivers by offering respite from the ongoing concerns of caring for a loved one and by supporting the best functioning of their loved ones through participation in the therapeutic program. • The relationship Charles House maintains with enrolled families. • Program administration assures that all aspects of the program are in compliance with the state rules for annual certification. 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 Enrolled families in the funding year will have the capacity of continue providing care in the 50% home and not require,or delay,residential care placement for their participant/enrollee. Families will report in the annual evaluation survey satisfication with the Charles House programs 50% Charles House Association will continue to surpass the NC standards and maintain state 2016 certification to operate as an adult day program. Certification DocuSigned by: eaut 5tuxr Executive Director 11/2/2016 Certified by: 6F28 a�sSGasaBe Title: Date: (Provider's Signature) DocuSign Envelope ID:78F84828-4CC5-4A5B-B256-33C571A84687 CHARHOU-01 MROBERTS AAcoRCP" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �--"' 9/14/2016 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: Summers Thompson Lowry,Inc. PHONE (919)9684472 FAx 919 9424221 100 Europa Drive (A/C,No,Ext): ) (NC,No): ( ) Suite 571 E-MAIL ADDRESS: info @STLinsure.com Chapel Hill,NC 27517-2393 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Philadelphia Ins Co INSURED INSURER B: Charles House Association INSURER C: Paul Klever 751 Sunrise Road INSURER D: Chapel Hill,NC 27514 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 INSD SUBR POLICY EFF POLICY EXP VD POLICY NUMBER W LIMITS (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PHPK1466031 05/10/2016 05/10/2017 DAMAGES( RENTED 100,000 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 PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER: Emp Ben. $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A ANY AUTO PHPK1466031 05/10/2016 05/10/2017 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NATO-OWNED Pera cdent)AMAGE X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE PHUB533292 05/10/2016 05/10/2017 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ 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 Molestation/Sexual PHPK1466031 05/10/2016 05/10/2017 Agg 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) For Information Purposes CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Government THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Or Or Box 0181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough,NC 27278 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD