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2016-634-E Finance - Historic Hillsborough Commission - Outside Agency Performance Agreement
DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 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 Historic Hillsborough Commission, a not-for-profit corporation, located at 319 N. Churton Street, Hillsborough,NC 27278 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Historic Hillsborough Commission 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 8857. 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 $2,214. 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. (Historic Hillsborough Commission) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 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. (Historic Hillsborough Commission) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 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. (Historic Hillsborough Commission) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 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 Historic Hillsborough Commission 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: (Historic Hillsborough Commission) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 County: Finance &Administrative Services Provider: Historic Hillsborough Orange County Commission Post Office Box 8181 319 N. Churton Street Hillsborough,NC 27278 Hillsborough,NC 27278 16. E ntire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and bthgagiAthe Provider F ti 11/3/2016 Ci9bt5L/L315J4FC... , Date For and o ti„utf Orange County Government b000tA,ln,lG Numwt14'SLU 11/4/2016 00379948755E 7... Bonnie Hammersley, County Manager Date (Historic Hillsborough Commission) Orange County Outside Agency Per/onnance Agreement Rev. 8/16 DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 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 Signed by: U _ FI Executive Director 11/3/2016 Certified by: E3g6827231534FC_. Title: Date: (Provider's Signature) (Historic Hillsborough Commission) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 Exhibit A Provider's Outside Agency Application APPLICATION S( mBNIITIAL CHECKLIST FOR OFFICE USE ONLY Recelved By Agency Historic Hilisborou.h Commission Date/Tie Complete Y N Program(s) Visitor Se ryices at the Burwell Schopi Historic Site For CDBG & HOME - Section Subsection HUD Regulations 1. Cover Page 2. Agency a. Agency's Years in operation 24 CFR 570,506, information b. [2]. Agency's Purpose/Mission 570 507, 57o610; 24 CFR Pans 84 or 85 c. Agency's Types of Services Provided Agency's Experie ce e. Li Other Pertinent information 3. Program/ a. El Type of Application and Program identified 24 CFR 570200(a), Project b. Of Summary of Program 570.201-570 208, information - c, El Description of Identified Need 507 503 (for c ch d r- Descriptio of P,p,datIOrI to be Served program/ project for e. Li Activity Manager and Location Description f. elf Activity Implementation Timeline which funding is requested) g. LI Agency Collaboration h. El Describe Impact of Reduced/No Allocation L El Other Pertinent information j. Col pleto Target Pop lati nii3e eficiary Chart k. LI Complete Schedule of Positions I. ix Signed Conflict of Interest Disclosure m. El Complete Work Statement DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAN 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 progra I funding. 24 CFR 570506, project for 570 507, 570 601, which funding a. H Pro ra udget Worksheet 570 602, 570 607(b), is requested) b. Di Pr gram B dget Detail 570 611 24 CFR c. Ell 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. H Audit: Organizations receiving $300,000 or more ' OMB Cuculdr AV133 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. H IRS Federal Tax-Exemption Letter e. E Certificate of Insurance f. I List of Board of Directors 24 CFR Parts 84 or 85 g. Articles of Incorporation/Bylaws 24 CFR 570,208 h. D Authorization to Request Funds 570,500(c), 570.611 _J Authorized fficial dtsignation Solid Waste Program Fee (SWPF) Verification Main Application 1/25/2016 1:26:31 PM I , ? DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAIN APPLICATION 1 1. COVER PAGE (Each program requires a separate application.) j a) Applicant Contact Information Applicant Organization's Legal Name The Hillsborough Historic CornmissiorL Inc. Applicant Organization's Physical Address: 319 N Churton St Hillsborough NC 27282 Applicant Organization's Mailing Address: PO Box 922 Hillsborough NC 27282 Applicant Organization's Web Address: wvyw.burwellschool,org Executive Director: Kate Faherty Telephone Number: 919-732-7451 E-Mail: directorAburwellsohogrorg DUNS Number: 141818208 (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. The Burwell School Historic Site Visitor Services Project/Program Primary Contact and Title: Kate Faherty - Executive Director Telephone Number: 919-732-7451 E-Mail: director@burwellschooLorg c) Funding Request Identification 5 7, 0 Total Project/Program Cost: i$4501.0 Total Arnounl lot' Funds Requested:44-31411 f ,r , Proposed Use of Funds Requested (2-3 Line Maximum): The HCC proposes to strengthen & ik5./f7:1 expand visitor svcs @ the Burwell & to improve the walkability & safety for all visitors on property Please check all types, sources, and amounts of funding being requested. You must submit an application package for ea c 13 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 7 Loan — CDBG Construction (CH) $ E Grant E Loan r HOME CHDO (OC) $ Grant 7 Loan 0 HOME Other (OC) $ _ Grant Loan _ I Fltinian Se Iry ces: Er (ftrrboro $ E Chapel HOD 3 [iTi Orange County IF- II, d) To the best of 11,y knowledge 4,nd b,Llief all information and data in this applicatha'n ig , 0 ) true and current. The document has been duly authorized by the governing board of the 5,y0 applicant. Signature: -75/ ,...,„ _.7,,,, / cr"- ,.., x-C-dtive Director -7/:"""/---/..,„„, e/7 1 Date //,,: < "/A97/,> '3.,...arcl Chairperson Date Main Application 1/24/2016 7:18:02 PM DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAIN APPLICATION —• 2. AGENCY INFORMATION __1 Please provide the following information about your agency (Limit of 2 pages total): a) Fears..........................e roll on .PitteLIL:Incor:::,oration :,:11.on th/Ye:ail I 11.e 1115tOrie Fhit SOOni...),ugh. t OlnlifiSS i On (1111C) is a statutory commission established in 1963 by the NC Cleneral. Assembly and incorporated in January 1964. b) Agency's.Purpose/Mission 1.'he mission. (..if the Historic Hillsborough Commission, as stated in its bylaws, is "to. maintain and preserve the Burwell School historic Site; to interpret the history of 19th century .11illsborough for the enriclnnent of the public; and to celebrate and promote the culture and heritage of Hillsborough and Orange County.." c) Types of Services the Agency Provides The MAC and the Bu.rwell School provide a range of educational programs and experietices 'for ,,,isitors of ail ages, with an cmph.a.sis on history of the site itself and the people \\ho lived there d).Agency's Experience rvith Similar Programs as the Funding.Request the Commission and the Burwell School brings in school groups from local schools for educational modules that are very "hands -• on"; Girl Scouts participate i..n the ..Burwell School Patch .Pro,,,,rainn, and scores of students enjoy participation in the History Fun Days and Colonial Kids Days carried out in cooperation \\,:ith the Alliance for Elistorie Hillsborough. and the Orange Count) Flistorical Museum. The Burwell School offers a variety of educational modules for school.-age participants, such as wrhe Story of Elizabeth Keck.ly," "All Dressed I. (19th C. clothing)," lerbal. Remedies," and more. It is on this strong :.lbundation that the (lin.tirynlission wishes to but ki a newstier ()f tours and visnor experienees In support Of ViSitOr se.rvices the Conanission II-lust maintain the buildings and grounds to, be walkable and safe. For all historic properties -- the Burwell School is nearing its 200th anniversary -- maintenance and preservation of the site are essential to serving N."71.SitOl'S. e) Other Pertinent.1genc..,'In.,,,,nrination- Main Application 1/25/2016 1:26:31 PM DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAIN APi tICATlON PROJECT/PROGRAM INFORMATION Agency & Program Name' The Historic Hillshorugh Commission: Visitor Seryices the EILLLell School Historic Site 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 supplementai sections (Parts) as specified below' 17: human Services (Main Application Only) CDBG Non-Construction —(Main Application AND Part A) Li CDBG Construction —(Main Application AND Part A AND Part B) LIII1 !, 101,,,,,i1E. CHDO Set-aside — Ap.tication AND Part A) LI HOME Other — (10 ain A h'Illication AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Disabled Public Housing Program Category Youth Adult Elderly (not elderly) Neighborhoods/Residents Education x x Health and Nutrition Job Training Sports and Arts Activities Pre-School Activities After-School Activities Mentoring Transportation Housing Other: Please specify (local history & culture) x x x x x , a esao s eys s 'ullIned be II rlOt fi pac.)es Please provide the following information about the proposed program/project: ft))Summarize the program services proposed and how the program will address the chosen town/county priority? The Historic Hillsborough Commission proposes to (1) implement new visitor experiences at the Burwell School Historic Site, (2) build a structure that will provide volunteer opportunities for people of ALL ages in the local community and (2) improve the safety and walicability of the site. Main Application 1/25/2016 1:26:31 PM DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAhJ APPLICATlON (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 Orange County ilfasier Aging Plan fin 2112 - 2017. Goal 5, states: 'Frnpow(r ()Icier adults to engage in the community through volunteerism.„ lifelong learning, and civic activities; promote lifelong learning of older adults through increased access to continuing education classes and programs throughout the community." Every° proposed project clement this application supports this goal The Orange County .Board qt"Commissioners Statement qt"Guals and Priorities, adopted in 2009, states as goal ft6: "Ensure a high quality of life and lifelong learning tlxit champions diversity, education at all levels, libraries, parks, recreation, and animal welfare,°' Every project conwonent in this application supports this goal. Historical and cultural literacy for all is at the forefront of the mission of the Vlistoric Hinsborough Cornrnission„, along with a more in-depth understanding of the compl'exitie.s of antebeflum life and the corrosive effects of slavery that echo through our history. (d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries 1 Older adiOts„ (idelilified through serlh.-1- centers., rethemem cornrnia)i R through ,ildverth;ing fli(1 oun"each) who are iliac:rested i NstoQ, violunteering; research 2. All local citizens interested in volunteering at the Burwell School 3. All visitors to the site interested in the story of Elizabeth Keckly and Mary Todd Lincoln 4, N.Th;;itors of all ag,:s with fl 1 f increasit4! numbers and improving, their experience La the Burwell School (e) Who specifically will carry out the activities and in what location will they be carried out? All proposed activities will be overseen by the Executive Committee of the Historic Hillsborough Commission, which is comprised of the four officers of the HI-IC and the chairs of all working committees. The program will be implemented by the staff of the Burwell School Historic Site,specifically the Executive Director(.5 FTE(and two Docent Guides(aggregate .4 FTE), They will design and implement the new tours in consultation with the members of the HHC's Research Committee to ensure that the information is well-presented and comp Fete (Dpes:1kte.specificaliLthepgriod over which the activities will be carried oi.41,1he freguency Aria which the activities will be carried out,and the frequency with which services will be delivered.Include an implementation timeline. AA/ I to December 30, 2016:Planning and design of handrails:planning marketing and implementation of history teas, collect feedback from all participants in new scripted tourIsLoggping recruitment of Burwell Volunteers orientation event for volunteers identified local seamstress to reolicate Elizabeth Keckl. dress coin fete all desic.ills and:'ilans for'Kecisly cii,s_p/p_i Application for 1-/DC for handrail design. „Lepill2:1Z to„lp ne3Q2Q12LInstallecklyslisplay,for Feb ppeninT orlgoirig communication with Stilwell Volunteers for Volunteer ()pporlunotEes atau e iii ord.kg2iaz F r uhl ,rifiinhr er bon ir inCh eedback: :.7xmstaicilion and iim;Plli,otion car frail(handraql,s„: piluatalg acco212lished corrwrissroner vc.)1Lov'eers. qualler k,,as con tinae feedback coataaJea and atatyzed, Main Application 1/25/2016 1:26:31 PM e 6 0 DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAIN APPLICAllON g) Provide a buffeted 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 HHC and the Burwell School have been close partners with the other visitor services agencies in Orange County and Hillsborough through the Alliance for Historic Hillsborough of which the Commission is a a founding member The Commission is a very active mernber of the goverthrtg board of the Alltahce,wretch also rnctuders the followtog, • Ffistoticall Foundation of Orange County(Orange Co, trlistorical US e LIM) Hillsborough Chamber of Commerce • Preservation Fund of Hillsborough • Hiiisborough Arts Council • Historic District Commission The Alliance/Visitor Center coordinates several town-wide events with which the Burwell School is active including Colonial Kids Day, Living History Days,and more These activities are planned and will continue for 2016-17 if the Commission is able to continue to raise the operational funding necessary to support staff and the facilities costs associated with the School's operation, The Buniveli School aiso has a very collaborative relat anshrp vii.th the Hthdorough Garden Clieb,which canoes out ho day decorailnd at the School and holds events soIii as flower shows at the site as pad of tee ectscatton arid Etteattttftstation mission trt the town h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If allocations is not provided the Commission will not be able to make much-needed safety and accessibility upgrades to the front entrance of the Burwell School and will be unable to support the staff time required to expand services to elder adults and the expansion of educational resources featuring Elizabeth Hobbs Keckly, V'roil.1 ram/Proiect a) Complete the Target Population and Program Beneficiary Demographics Chart b) Complete the Schedule of Positions Chart for Program Staff c) Disclosure of Potential Conflicts of Interested must be signed d) Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of 101 data collection tools that will be used to verify achievement, of program goals and objectves, 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 appltcable in each category, Please indicate whether this project/program wiii serve, H Pers.,,wls H Ft ,usen-lds H Units Program: Program Beneficiary Demo raphics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 45% 45% 45% Female 55% 55% 55% 1 00% 1 00°/o 100% Total Main Application 1/25/2016 1:26:31 PM onnunign Envelope ID:rnnCoAo2-o7Eo-4:oe+FAn-CencAn71eAno [ /\- QoOtinu8d Provider's Outside Agency Application MAIN APPLICATION Of the females how many are single- female Head of Households (Omit for Human Services) n/a n/a n/a Ethnicity African-American 'i/o 20% American Indian or Alaska Native 96 Asian 3% 2% Caucasian Native Hawaiian or other Pacific Islander 1% 3% 4% Other Total 10096 100% 100%i Of the above how many � ------- -- - Hispanic/Latino UNKNOWN UNKNOWN UNKNOWN Of the abmve how many non' H(spanic/Lahmo UNKNOWN UNKNOWN Total | 5.00O � 5.O0O � 5.000 Age 0-5 years 6-18 years 19-50 years 51-61 years 62+ years Total Geographic Location Durham City UNKNOWN UNKNOWN UNKNOWN UNKNOWN UNKNOWN UNKNOWN Durham County UNKNOWN UNKNOWN UNKNOWN Car rboro I)NKNowN LAKNOWN UNKNOWN Chapel Hill UNKNOWN UNKNOWN UNKNOWN Chap& HUl Public Housing Residents UNKNOWN UNKNOWN UNKNOWN Orange County UNKNOWN I UNKNOWN UNKNOWN Raleigh UNKNOWN UNKNOWN UNKNOWN Wake County Total 0 0 0 Income Leve —See following chart (Onniitfor S) < 3O96Area Median Income 3.1-50% Area Median income 51-80% Area Median Income � 80%Area Median Income | � Main Application 1/25/2016 1:26:31 PM DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application 1 IAIN APPLICATION Total _ 0 0 0 Special Needs (0ount for HS) Elderly (Over 62) Disabled (not elderly) h-lomeless Peopie with H1V/Aids Total 0 0 0 DBG & HorvIE oNo" - Area Benefit Activities clbfrastructure and Public Facilities Street Census Tract Block Group Total Persons #LMI Persons • 2015 Area Me•i n Fa l Hy income Li Hits _ U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Income 1 1 2 J 3 4 5 6 r 7 8 1 Lev / i 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 an Application 1125/2016 1°26.31 PM DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAIN APPLICATION 115% AMI $54,266 $62,028 $69,791 [$77,481 $83,734 $89,916 $96,097 $102,278 http://www.huduser.org/portal/datasetsiilii115/FY2015 IL nc.pdf Ii.) Schedqie of Posit/4,ns 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). ' , : ---1 , 1 it provided, indicate: Position Titles % (R) FTE* Actual Estimated Projected % Total * = Position . Program Retirement 2014-15 2015-16 2016-17 Budget Vacant Staff+ Plan (H) Health Plan 32% , Executive D1rector 50 50% 27 000 25.250 217,000, 1 1 ' . i Docent/Support 40 40% 9,450 2,800 9,450 11% Volunteer ,25 10% 0 0 0 0% 1 i 1 J I 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, O + Denotes the percentage of staff t1rnernvorved w h Mos program • Catc,o,terte a Fa Tume EqunvaNent for a6 recorded vNuntee rtdars usMrg the fohoroAng Total Volunteer Hours =Volunteer FTE 1,960 Main Application 1/25/2016 1:26:31 PM DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 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 [11 L 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? E. c) Current benefibanies of the project/program for which funds are requested? Li 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. T. the Hst of my kno.,,HeAge and belkf all of the ab,Ilie information is true and current. I ackn wiedge and understand that the existence of a potential coi:Ilict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: /1: 721, 1/25/2016 Executive. Director , - Date (- Signature: ,„ 1/25/2•16 oard Chairperson Date Main Application 1/24/2016 7:18:02 PM ci 1 2 2) f 1 2 DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAIN APPLICATION I.) 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 shou0d out inc major activities the agency implements to accompfifish 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 os results use program results to indicate the actual measureable achievement of goals, If goals were not met, please exp(airI Main Application 1/25/2016 126:31 PM DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAN APPLICAT1.011"4 Program Activity 2 'firbt a/a Burwell Volunteers,Community :Budding freftli easel: Program GNP ri/a Eyaidate ruzied frn Shift:Sall Stye.freavel(Valhateers voiurneer The(Una anti Kent:hough organization to 'Commission established an ad support Berme haat planning committee in 70172 Sabana infroter.and to pop y of caa "rhe,:kawe a V ca are aaea of commuraty?than bers. traihicluati,at ha ages,including , many seethe citizens,have asked Ifs," optfortunita to volunteer aft the Burwell School. Thy nay the pot easel to awe some very I pressing,heeds af the sae which carbine be hulia itpp by the part ,time eel'ref the 27 craP le tharadear:conetwothg tours: ilbermigemaas,garden Irrainfenamen and arthathopmend , sae haaddenonce(small redoes, upkPPP,fee;genealogical' research Performance Measures Coonnithern crane(re Perna (ha,cod thecnear cad ea(thence"(donathe thearpears e an ahead,ha Banana Program Results (pa Corrahossean The riarawek thatuatents:Pod( establishes Burwail lestalelahed and opera bone and Volunteer Com aflenie leyakbeest art an papaont,neth --a- 'Program Activity 3 Burwell ScPop I Sae Burwell School Size PP rit propose to tristan a Row, othanaored area maIntannera and 'voltage LED lighting system for preserved preverzatia, Ithe front access to the Bunmell School,from the sreips VI org ig 4 o ogir path,.UP tO nom entrance'to the alarWeri ,School is extremely dark at night fvfaris thrthors perk along atheas Street and enter the building using steps ifp ham ttie strae, then along a faunae 04thway set acne the gcass along a large nonethera hedge,and huteiv hia the. ride heats where there fri one' 'dela(Atha:aiah( ahnharoaa the coon( C?k,':,r1.g. ape oca a I ese an oe.treathearces Pada trra sled :have received numeroun sairnizanfa f effect War path lights nave proven ethrefactely acarkequath and often at ol due to iriaderbyee solar gam pp pP pp r ies Program Gogh Moirogin airg primeme iMairogin and hearthead wa Air bila y and v,afety ,remora az a as Doomed Screen'remora.sae dr, ,oa'rt.(a fiSio we SttYCA), P. rahapon ehatamera Performance Measures lihehrairit and upkeep Repairs and upkeep L■ght ng System operational dark accomphshati promptly accomplished until 17arn,grounds mthataanth worn pt,lat sef for eationt Program Results Soo iiigfie and worknaft Sae r see and Front.Entrance to Burweil Schaal achadicon for vectors, sforking condition for seedy and otharthwely illuminated rehears P:rar evening events arid viznort m energy Wheezy marmier The lava mince:. earned(were ear nee nod(weer.PPd loPP(atonal by the the beginning, log Drogigro:Savior,rime in Oesher, 2 0.16 Grounds ma her nett and maw ad to ensure an Applicata,' 13 M 112 /2016 ? : 1 M P rimming iseeson — „ DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAIN APPLOCAT1ON 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form f-r 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, 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, aflocate costs to the use of shared space vehicles or equipment. Exam le 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 Counsel* reacher (-.;lass prep $25 48 hours (4hrs/mth A"1.2 roUis) $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 $9,000 Main Application 1/25/2016 1:26:31 PM p ,; 1 5 5 1 1 5 DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAIN APPUCATIKA Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed, Program: Burwell School Visitor Services — Ex•ansion/Da time Histo Teas for Older Pa,oulation:Yea, la Cot Elements I C0 1:(4 Quantity/Unit of measure Subtotal($) Speaker Honoraria $50,00 3 events $150 00 Planning, Marketing $27 00 10 staff hours $270,00 Site Preparation $105 00 3 events $315 00 Staffing AdemnistrafR)n Evahu)tIon $37 00 2 his x Exec Director, docent $333 00 time x 3 events 1 Total $1068.00 C.) Cost per Unit ( t d 2015- Projecteh 201 -i 7 Actual 21.14-15 16 Total Cost of Program NA NA $1,068.00 Total # of Units NA NA $140.00 Cost Per Unit NA NA $7.63 Program. Bq, ell Sehppl Historic Site "Bu eli Volu tjf Comfpurlit — Buildin• YEAR ONE Cost Elements I Col(4 . Quantity/Unit of measure Subtotal(;) Administration $27 00 4 hours/month staff x 12 months $1,296.00 Printing & Mailing for marketing, record $325.00 60 volunteer packets, files, $650,00 keeping, applications and record forms mailings x 2/year Community Volunteer events $250 00 2 x year $500 00 Total $2,446.00 d.) Cost per Unit ,,t1,„,.:1 2011445 1 Estimated 2015- 11 16 Proj,ct,cl 201*-17 Total Cost of Program NA A $2, 6.00 Total # of Units NA NA 5,000 visitors $0.50/visitor Cost Per Unit NA NA Main Application 1/25/2016 1 :26:31 PM 6 6 { 1 6 DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAIN APPLICATION Program: Improved Safety and Accessibility for Visitors to the Burwell School Historic Site Cut Elements Co:1 ($) 1 Quardity/Unit of mea,ure 1-subtob1(s) Low Voqaqe LED kghtog system for front $600 , 300 watt transformer ',F, LIED step , $600 00 pathway and entrance to site and path lights + 100 ft low voltage line Installation of handrails at front entrance to $480 2 handrails x 4 hrs each $960,00 the Burwell School construction and 2 hrs installation @$40/hr Pressure treated rn work lumber 1 $200 1 1 $200 00 HDC Application Fee $20 1 $20.00 Exterior latex primer and paint $48 1 gallon $48.00 Site Maintenance and Visitor Safety $110 Grounds care x 24 visits $2,640.00 $ Total , $4,46800 J 1 e.) Cost per Unit 1.-- I - 1 1 Actual 2014-15 1 Estimated 2015 Projected 2016-17 16 To I C St , 4 Program $264, l,,,, $264,.00 $4668 ,0 Total # of Units [5,000 Cost Per Unit $0.53 5,000 5,000 $0.53 $0.94 Program: Elizabeth Keckly Exhibit Expansion 7 Elements Cost($) [Quantity/Unit of ml-asure i Subtotal ($) 1 , Small Scale 19 Century Dress $500 One dress, reduced size $500.00 Reproduction reproduction & produced by hand 30 tall dress display form $75 $50 estimated plus $25 shipping $75,00 Exhibit Sign and brochure production r$300 200 tri fold brochures ($250) and $300.00 (design and printing) 8 x 10 exhibit sign ($50) I 7 i Total $875.00 Main Application 1/25/2016 1:26:31 PM DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A- continued Provider's Outside Agency Application MAIN APPLICATION f.) Cost per Unit Actual 2014-15 Estirnall:11 2015- 16 Projeci'A 2016-17 Total Cost of Progra,i,,,, , NA , $875.00 Total # of Units NA NA 5,000 Cost Per Unit NA NA $0.17 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)„ 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 1:26:31 PM DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 t A - continued Provider's Outside Agency Application Section VI.Financial Data Operating Budget for Entire Agency AGENCY NAME: Historic Hillsborough Commission Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 6,158 $ 7,500 $ 7,500 0% Agency Generated Revenue(fees) $ 34,090 $ 26,850 $ 26,850 0% Local Government Grants: Orange County $ 7,000 $ 7,000 $ 8,857 27% Town of Chapel Hill 0 Town of Carrboro 0 Other Local: Town of Hillsborough $ 23,000 $ 16,000 $ 16,000 0% Other Local: 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way 0 State Government 0 Federal Government 0 Other Grants:Kirby $ 10,000 $ 10,000 $ - -100% Other Grants:Covington Foundation $ 9,000 $ - $ - 0 Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: \ $ - $ - $ - Total Agency Revenue $ 89 248 $ 67 350 $ 59 207 -12% AGENCY EXPENSES Compensation $ 47,237 $ 32,015 $ 36,450 14% Rent&Utilities $ 6,740 $ 7,536 $ 7,756 3% Supplies&Equipment $ 3,861 $ 4,200 $ 5,000 19% Travel&Training 0 Other Expenses: $ 32,438 $ 30,532 $ 29,294 -4% Please list 3 largest"Other Expenses": $ - $ - Total Agency Expenses $ 90,276 $ 74,283 $ 78,500 6% SURPLUS/(DEFICIT)FOR PERIOD: I $ (1,028)1 $ (6,933)1 $ (19,293)1 -178%I DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Historic Hillsborough Commission Program Name: Funding Award: $8,857 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel and Operational Expenses 8,857 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. • Improve access to educational information and increase awareness of cultural programming by developing new content for the Burwell School website • Maintain and preserve the Burwell School Historic Site, which requires frequent improvements for the continued enjoyment and safety of it's visitors. • 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 Install a low-voltage LED lighting system for the front access to the Burwell School Dark— 12am Incoporate Volunteer Opportunities 40 volunteers Burwell Activities and Individuals Served 5,000 people Docu/Signedd by: ,y�-U " I Executive Director 11/3/2016 Date: by: E396827231534FC_. Title: Late. (Provider's Signature) DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 DATE ttgtfAitfOrrirq ACGREI CERTIFICATE OF LIABILITY INSURANCE 1/21/2016 6.------ . 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 1 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 pollty(les)must be endors .. If SUBROGATION IS WAIVED,subject to the tell ,Li;and coadttions of the looney,certain poltclee may require an endorsement A statement on this certificate does not confer rights to the contineafe hofder in We or such endordement(s), ! . — PRODUCER NAME j. DAVID BALLARD , BALLARD AGENCY INC PHQ'NIE (919)732-2158 ' NC NO919)732-9636 PO Box 1559 0055ba11ard@ba11ardagencyinq,.com coin Hillsborough, NC 27278 INA URER(a) AFFORDING COVERAGE HAMS INSURER A:GREAT AMERICAN INSURANCE CO INSURED HISTORIC HILLSBOROUGH COMMISSION INSURERS:GREAT AMERICAN INSURANCE CO I PO BOX 922 jNsuREIR c 1 ILLS °ROUGH, "I 'C 27278 oNsuFtER,0 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LMISTED BELOW HAVE BNEYENCOISNSUEDCTTOONTHOETNINESRURDOEDCutrENETD ABOVREEFSOPRECTTHETOPOLICICYHPTEHRIISOD ICNEDNIrICADTE, NOTreTHESITSASNUDEIDNG6NANY RYEIF.i,IEUNIRTEAMINE TTNETEINRSUORNCCOENADFITIF, 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, .. , _,....., . OMR OR fft *)f TvPr, oF IINSURANCE POLACY NUMBER , ttattfT1'.,P , ! 4i.D .fr,rYY. Lwrrs _ .. _{ COMMERCRAI. OENERAL 6.11LIWO,,mr EACH OCCURRENCE $ 1,,0002_000 1 X}1 , TAMAGETOTEEfT TlEtr-- CLA1MS-MADE L dui OCCUR I I 1 PROM $ Ea occurrence , $ 100,000' ! , , ! 12/11/15 '12/11/16 MED EXP(Ahy one person) , s 5,000 - PAC4816275 1 Al 1 1PERSONAL&ADV INJURY ' 5 1,000,000 1 1 GEN1 AGGREGATE LIMIT APPLIES PER, GENERAL AGGREGATE !,$ 3,000„000 X POLICY n 78,--. D Loc I OTHER: ! ! ! ! , 1, PRODUCTS'COMP/OP AGGIs 3,000,000 Ti $ ..... AuTOMOSILE LLABUTY , 11E_Lt"PARTIL ' ANYALIE0 ALL OWNED ---- SCHEDULED ' :'I , ' , BODa`E nailitrer(Por parson) $ BODILY INJURY(Per acciderd)I $ ' AUTOS , AUTOS WN NON-OED , $ HIRED AUTOS AUTOS 1 1 (Per acciden1) , ! , S X UMBRELLA um l OCCUR umB4816276 ' EACH OCCURRENCE $ 1 i 000,000 g EXCESS LIAO ! CLAIMS-MADE I AGGREGATE $ 1 000 000 I ' DED I RETE,NTION$10 000 12/11/15 12/11/16 s 1, , 'WORKERS COMPENSATON 1 IIIII S1'1'AIWIT1 11111 '1E,,11""1 AND EM,-1„,0YERS'LVdtlLTY WY PROPAJETOFWAPIXEORAFXECLPT WE r—1 I E L.EACH ACC*E.NIT $ OFFICER/MEMBER EXCLUDED? 14 i A 1 QMAndalory la NH) El DISEASE-EA EMPLOYE $ IEjn5dRIPTIONVI'l!PERATIONS !,:low , I I ! E.L.DISEASE-POLICY LIMIT!S , r , 1 , , , , ! ' I ! , ! ' 11DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (ACORD 101 Add/Vona!Remarks Schedule,may be attachoddrnore apace Is required) , , CERTIFICATE HOLDER . , CANCELLATION . . GE C01111':T'i' SHOULD ANY OF l'HIIII ABOVE DESCRIBED POLICIES (9 CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WU BE DELIVERED IN PO %OX 8181 ACCORDANCE WITH WE POLICY PROVISIONS, I HILLSBOROUGH, NC 27278 AUTHORIZED REPRESENTATIVE , / ■ 041988-2014 ACORD CORPORATION, All' !1.hts reserved, ACORD 25(2014/01) The ACORD name and logo are r glstered marks of ACORD DocuSign Envelope ID:FO3CBAC2-B7E2-4CDB-AFA6-CB52A071BA00 flATEJM!ODFFYYY) -' AWRD CERTIFICATE OF LIABILITY INSURANCE 1/21/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE, AFFORDED BY THE POUCIES 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 e policy,certain policies may r'equ� an endorsement A statement on this cent'este does not confer HOW to the cora cat holder In lieu of such ender ement(s): PRODUCER -,._..,._-_..._.... .—,.— .��. �_„_ aE "s U.DA'V'ID ........-�.. o-� .,, .^- ..,...-...-� BALLARD AGENCY INC I PH•NE (919) 732-2158 919)732-9636 PO Box 1559 '' enc inc. I„ _- (FVFoNo DR ssballard @ballarda• Y com Hillsborough, NC 27278 Ma,eser¢rel AFFORDING COVERAGE RAMO INSURER A:GREAT AMERICAN INSURANCE CO INSURED HISTORIC HILLSBOROUGH COMMISSION INSURER B,: ' 1 PO r OX 922'. r I °eSURER.I�- ...� .w..w 'G3IT�rT.rSaORt•JT�GI� NC 27278 � oR�S DRI'R D 1 ..... ...._ ........._ � INSURER E: .._..._ . ... .,.._.,. .. ... ... INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS OS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTMTHSTANDING 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, erg. �.. • IILie,' TYPE OF VNSl.URANC:N � r 'rem POU 14'r N4.UMBER m„n�anrl�I�anyY JsMM DowYY LIMITS w.. ,... � etiu:rl��r EACH OCCURRENCE _..... _... RREtl"BiC"IF RFNTED- CLAIMS-MADE I„.w l OCCUR PREMISES(Ea occurrence) ' ! MED IELP(Any one person) „ $.. I PERSONAL A ADV INJURY S GENIC AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ POLICY j PRO pi LOC •COMP/OP AGG $ JECT PRODUCTS OTHER: COMBINED SINGLE LJT S AUTrMQB LWLrrY Lt ALL A BOER)”INJURY(Per person) S ED SCHEDUCEO EDGILY INJURY(Per accident) yr..... AUTOS AUTOS NON-OWNED S HIRED AUTOS I AUTOS (Par strident) S . ' UMBRELLA LIAR OCCUR EACH OCCURRENCE $ r EXCESS Li.; CLAUMS-MADE AGGREGATE S ©ED RETENTIONS Is SWtIORHLRS I OmMPENSATION CC PTR OTH LOYERS°L^°5'OW 1 STATUTE _ . 1 ER AND ESP : Y,_nrr wrIrnate6LPAmTNEIVEXECtrrofkr. . N N n 'd. EACHACCUENr _...S ur c rMLStaE EXCLUDED? (Wan®uery In MITI E.L DISEASE-EA EMPLOYE S Ityaa daEaiee under DESGIRIP 'TIDN Of OPERATIONS below Et DISEASE-POLICY UNIT $ $1,000,000 OCC WRONGFUL A DIRECTOR & OFFICERS EPP4917808 1/21/1'•1/21/17ACTS $1,000,000 OCC LIABILITY EMPLOYMENT PRACTICES DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (ACORD tog Addili©nal Remarks Schedule,may be attached rf more space is required) � CERTIFICATE HOLDER CA NCELLATION 0', '1 GE CO i^bTY SHOULD ANY OF THE' ABOVE DCSrRIRFO POLICIES BE CANCELLED BEFORE , "O '18k. TilE 'EAPI TIe�, -1'-FE THEREOF, NOTICE WILL .1E •SLIVERED IN BOX. ACCORDANCE WITH THE POLICY PI2OVISIOia5. HILLSBOROUGH, NC 27278 AITHO"';'ED REPRESENTATIVE /-,-.'"'' .,‘.'I'', , /.. ,.,,, .... "' t 19.;-2014 ACORD CORPORATION. All rights reserved. ACORD25(2014101) The ACORD name and logo are re stored marks of ACORD