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2016-646-E Finance - Big Brothers Big Sisters of the Triangle, Inc. - Outside Agency Performance Agreement
DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 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 Big Brothers Big Sisters of the Triangle, Inc., a not- for-profit corporation, located at 808 Aviation Parkway, Suite 900,Morrisville,NC 27560 ("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 Big Brothers Big Sisters of the Triangle, Inc. agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2016 to June 30, 2017. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit"A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 4000. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $1,000. 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. (Big Brothers Big Sisters of the Triangle,Inc.) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 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. (Big Brothers Big Sisters of the Triangle,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 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. (Big Brothers Big Sisters of the Triangle,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 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 Big Brothers Big Sisters of the Triangle, Inc.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: (Big Brothers Big Sisters of the Triangle,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 County: Finance&Administrative Services Provider: Big Brothers Big Sisters of the Orange County Triangle, Inc. Post Office Box 8181 808 Aviation Parkway, Suite 900 Hillsborough,NC 27278 Morrisville,NC 27560 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 beh lfetifYt e Provider L 6144 br 11/11/2016 5E4774DA5B354D3... Date For and f fbOrange County Government botiutAAt, tka" tt rstui 11/11/2016 0637994B755E477... Bonnie Hammersley, County Manager Date (Big Brothers Big Sisters of the Triangle,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 ATTACHMENT "A" Orange County Certifications—FY 2016-17 Outside Agency Performance Agreement Chief Contact,Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title,residential address;phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DocuSigned by:::�, II,,,,� bru- """" CEO 11/11/2016 Certified by: SE4ZZIDASR354123 Title: Date: (Provider's Signature) (Big Brothers Big Sisters of the Triangle,Inc.) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 Exhibit A Provider's Outside Agency Application MAIN APPLICATION APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency Big Brothers Big Sisters of the Triangle Date/Time Complete Y/N RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRrrRRRRRRRRRRRRRRRRRRRRrrRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRrrRRRRRRRRRRRRRRRRRRRRrrre Program(s) Community and School-Based M entori n g Subsection For CDBG & HOME - Section HUD Regulations 1. Cover Page a. ❑ Applicant Contact Information b. ❑ Project/Program Contact Information c. ❑ Funding Requests Identified d. ❑ Signed Application Cover Page 2. Agency a. ❑ Agency's Years in operation 24 CFR 570.506, Information - b. ❑ Agency's Purpose/Mission 570.507, 570.610; 24 c. ❑ Agency's Types of Services Provided CFR Parts 84 or 85 d. ❑ Agency's Experience e. ❑ Other Pertinent Information 3. Program/ a. ❑ Type of Application and Program Identified 24 CFR 570.200(a), Project b. ❑ Summary of Program 570.201-570. 208, Information - c. ❑ Description of Identified Need 507.503 (for each d. ❑ Description of Population to be Served program/ e. ❑ Activity Manager and Location Description project for f. ❑ Activity Implementation Timeline which funding g. ❑ Agency Collaboration is requested) h. ❑ Describe Impact of Reduced/No Allocation i. ❑ Other Pertinent Information j. ❑ Complete Target Population/Beneficiary Chart k. ❑ Complete Schedule of Positions I. ❑ Signed Conflict of Interest Disclosure m. ❑ Complete Work Statement Main Application 5/24/2016 8:51:19 AM 0 I:° 1 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208, each expenses for the entire program and ALL sources of 507.503 program/ funding. 24 CFR 570.506, project for 570.507, 570.601, which funding a. ❑ Program Budget Worksheet 570.602, 570.607(b), is requested) b. ❑ Program Budget Detail 570.611 c. ❑ Cost Per Unit 24 CFR d. ❑ Agency Operating Budget Worksheet 570.502-570.504, 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A- 122; 5. Supplemental A. ❑ Part A: CDBG & HOME Sections (as B. ❑ Part B: Construction/Rehab applicable) 6. Attachments a. ❑ Audit: Organizations receiving $300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ❑ NC Solicitation License d. ❑ IRS Federal Tax-Exemption Letter e. ❑ Certificate of Insurance f. ❑ List of Board of Directors g. ❑ Articles of Incorporation/Bylaws h. ❑ Authorization to Request Funds 24 CFR Parts 84 or 85 i. ❑ Authorized official designation j. ❑ Solid Waste Program Fee (SWPF) Verification 24 CFR 570.208, 570.500(c), 570.611 Main Application 5/24/2016 8:51:19 AM 0 I:° 2 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: Biq Brothers Biq Sisters of the Triangle, Inc. Applicant Organization's Physical Address: 808 Aviation Parkway, Suite 900, Morrisville, NC, 27560 Applicant Organization's Mailing Address: 808 Aviation Parkway, Suite 900, Morrisville, NC, 27560 Applicant Organization's Web Address: www.bbbstriangle.orq Executive Director: Kimberly Breeden Telephone Number: 919-850-9772 E-Mail: Kbreeden@bbbstri.orq DUNS Number: 793500641 (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: Community and School-Based Mentorinq Project/Program Primary Contact and Title: Marian Larson, Grants Coordinator Telephone Number: 919-850-9772 E-Mail: mlarson@bbbstri.orq c) Funding Request Identification Total Project/Program Cost: $245,500 Total Amount of Funds Requested: $15,000 Proposed Use of Funds Requested (2-3 Line Maximum): These funds are requested to continue to support our Community and School-Based Mentorinq Program in Chapel Hill, Carrboro, and all of Orange County for children ages six to 14. Please check all types, sources, and amounts of funding being requested. You must submit an application package for each funding source. *The Participating Jurisdiction reserves the right to fund projects from any funding source, subject to eligibility and funding constraints. ❑ CDBG Non-Construction (CH) $ ❑ Grant ❑ Loan ❑ CDBG Construction (CH) $ ❑ Grant ❑ Loan ❑ HOME CHDO (OC) $ ❑ Grant ❑ Loan ❑ HOME Other (OC) $ ❑ Grant ❑ Loan Human Services: ® Carrboro $3,000 ® Chapel Hill $6,000 ® Orange County $6,000 Main Application 5/24/2016 8:51:19 AM .. g 3 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION 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: � � 1/23/16 Executive Director Date �.71"4"'" Signature: 1/23/16 Board Chairperson Date Main Application 5/24/2016 8:51:19 AM P of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month/Year) Years in Operation: A Big Brothers Big Sisters agency has operated here for 17 years. Big Brothers Big Sisters of the Triangle, which is the result of a merger of two BBBS agencies, has operated here for ten years. Date of Incorporation: 10/26/1998 b) Agency's Purpose/Mission Our mission is to provide children facing adversity with strong and enduring, professionally supported one-to-one relationships that change their lives for the better, forever. c) Types of Services the Agency Provides Community-based mentoring provides children from single parent homes or other children in need of adult role models with a one-to-one mentor relationship with a volunteer from the community. These volunteers receive extensive screening and training from our Enrollment Specialists and our Match Support Personnel. A careful process is followed to make a quality match between youth and the appropriate volunteer in order to promote long-term relationships. The Community-based "Bigs" routinely provide 8-10 hours a month of quality one-to-one time for each child. This particular program allows us to reach children throughout the county who may otherwise not have access to services. These "Bigs" play an integral role of the lives of their "Littles" by providing a stable adult role model to help guide these children in the right direction. School-based mentoring provides mentors to children on their school campus during and after regular school hours. Our partnerships with many local schools allow school counselors and teachers to refer children who are struggling with class work or need extra attention to build better social skills and improve classroom behavior. Our school-based matches meet for one to two hours each week. They read together, do homework, or play educational games, among other activities. School-based Bigs work to improve their Littles school attendance and academic performance and help them understand the importance of staying in school, graduating, and achieving higher education. They also tend to have more Main Application 5/24/2016 8:51:19 AM 0 I:° 5 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION direct conversations about school performance and get access to more information on the Littles' homework and grades through interaction with their teachers. BBBST also provides a variety of monthly enrichment activities for "Bigs" and "Littles". We work with corporate sponsors and local donors to provide opportunities for the matches to attend sporting events, movies, museums, field days, and many other activities. d) Agency's Experience with Similar Programs as the Funding Request After more than 100 years, Big Brothers Big Sisters of America remains true to its founders' vision of bringing caring role models into the lives of children. We are the oldest and most respected mentoring agency in the country. With that, our core program — Community and School-Based Mentoring — is the cornerstone of our agency. We have the hard data to prove that our mentoring helps children increase self-esteem, overcome adversity, improve school behavior and academic performance, and avoid risky behaviors, like drug use and truancy. National research shows that after 18 months of spending time with their Bigs, Littles, when compared to those children not in our programs, were: 46% less likely to begin using illegal drugs; 27% less likely to begin using alcohol; 33% less likely to hit someone; and 52% less likely to skip school. Since we offer our services free of charge to parents and their children, we must fundraise to cover all program costs. Throughout our 17-year history, BBBST has received consistent support from a number of government entities, foundations, corporations, and individuals to pay for these program costs. Our continued relationship with Orange County, Town of Carrboro, and Town of Chapel Hill has helped us continue our crucial work in making a difference in the lives of at-risk children in the Triangle area. Main Application 5/24/2016 8:51:19 AM 0 I:° 6 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Big Brothers Big Sisters of the Triangle As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: Human Services (Main Application Only) ❑ CDBG Non-Construction — (Main Application AND Part A) ❑ CDBG Construction — (Main Application AND Part A AND Part B) ❑ HOME CHDO Set-aside — (Main Application AND Part A) ❑ HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Program Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education x Health and Nutrition Job Training Sports and Arts Activities Pre-School Activities After-School Activities Mentoring x Transportation Housing Other: Please specify Main Application 5/24/2016 8:51:19 AM P of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION Program/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b) Summarize the program services proposed and how the program will address the chosen Town/County priority? Our Community-Based program allows us to reach children throughout Orange County, Chapel Hill, and Carrboro who need an adult role model in their lives. Community-Based Bigs routinely provide two hours a week of quality one-to-one time for each child for at least one year. These Bigs play an integral role in the lives of their Littles by being good listeners, by giving the Littles a stable adult role model to help guide them in the right direction, and by exposing the Littles to a variety of cultural, community, and sporting activities. Our School-Based program allows school counselors and teachers to refer children who are struggling with class work or need extra attention to build better social skills and improve classroom behavior. Many of the children referred to our School-Based Mentoring Program are academically at risk— struggling with negative perceptions of school and teachers, time management, focusing, and test preparation. School-based mentors are trained to work with their Littles to offer a positive perspective on school, model productive study habits, and encourage improved relationships with teachers and other adults. Fourteen percent of our Littles and 15% of our Bigs reside in Orange County. Results of our 2015 Youth Outcomes Survey show that social acceptance, risk attitudes, scholastic competency, and parental trust, among others, are all markedly improved in our Littles after only one year in our program. This is proof that our program helps to prevent young people from going down the wrong path, making your community safer and more successful. 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 number of youth living in poverty in the Triangle has increased substantially, along with increases in juvenile crime, school dropout rates, childhood obesity and other related health and social problems. There are more than 94,000 children who quality for free and reduced lunch living in our area, and most are minorities from single-parent households. Children who live in our highest crime-ridden neighborhoods, attend our most struggling schools, who become victims of violence and abuse, and/or who have an incarcerated parent are exponentially move at risk for "falling through the cracks." We operate in the belief that inherent in every child is the ability to succeed and thrive in life. These children need positive role models to show them hope for a brighter future, and our mentors help them achieve this. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries? Main Application 5/24/2016 8:51:19 AM .. of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION Fifty-nine percent of children in our program are male, while 41% are female. The majority (72%) are African-American; 10% are Caucasian; 6% are Hispanic; 11% are Multi- Race; and 1% are Asian. Seventy-three percent quality for free/reduced lunch, and 75% live in single-parent households. Twenty-three percent have at least one incarcerated parent. Our programs target the children who need us most. Any child ages 6-14 with an identified need can be enrolled in our program. Parents/guardians recognize the potential of their children better than anyone. By starting a child in our program, parents are introducing a path that is brighter and more promising. e) Who specifically will carry out the activities and in what location will they be carried out? Our adult volunteers, or"Bigs," carry out our program activities. They receive extensive screening and training from our Enrollment Specialists and our Match Support Personnel. A careful process is followed to make a quality match between youth and the appropriate volunteer in order to promote long-term relationships. Community-Based Bigs routinely provide 8-10 hours a month of quality one-to-one time for each child. Spending time together out in the local community is primarily how Community-Based matches develop their relationship. School-Based matches spend at least one hour each week at the Little's school campus. However, our School-Based Mentoring Program isn't limited to the classroom. Of course, some Littles do talk with their Bigs about class, do homework, or read together, but it's perfectly fine to shoot hoops in the gym or play on the playground. Our current School- Based programs in Orange County include Estes Hills Elementary School, Mary Scroggs Elementary School, Philips Middle School and Smith Middle School. f) Describe specifically the period over which the activities will be carried out, the frequency with which the activities will be carried out, and the frequency with which services will be delivered. Include an implementation timeline. Our activities will continue to be carried out all throughout the year. Community-Based matches spend 8-10 hours per month together, while School-Based matches spend at least one hour a week together during the school year. Our Match Support Specialists provide on-going monthly support to each match. After the initial match process, volunteers, parents and children are contacted monthly to ensure the effectiveness of the service delivery model. Every day our Match Support Specialists are on the phone with our Bigs, Littles, and parents or guardians about their match experience, securing anecdotal evidence on the impact of the match. g) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Main Application 5/24/2016 8:51:19 AM P of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. • North Carolina Department of Public Instruction, which supports our efforts to help at-risk children —They endorse our programs every year. • North Carolina Department of Juvenile Justice — We get referrals from them to mentor children. • Durham Housing Authority and the Housing Authority of Wake Counties — We get referrals from them to mentor children they determine are in need of our services. • JD Lewis Community Center in Raleigh • Passage Home in Raleigh • YMCA of the Triangle, including the Chapel Hill/Carrboro YMCA • Area Boys & Girls Clubs - We get referrals from them to mentor children they determine are in need of our services. Through United Way, we are in a two-year collaboration with Boys & Girls Clubs and six other youth serving agencies. • Communities in Schools - We get referrals from them to mentor children they determine are in need of our services. Through United Way, we are in a two-year collaboration with Boys & Girls Clubs and six other youth serving agencies. • School Districts of Orange, Durham, and Wake Counties — We work directly with guidance counselors and social workers in schools where we have official mentoring sites, and we get referrals from schools to mentor children they determine are in need of our services. • Leadership and staff of Orange, Durham, and Wake Counties • Leadership, staff, and students at NCCU, Duke University, UNC-CH, and NCSU • Numerous African-American and Multi-Ethnic Churches in the community • National African-American fraternities: Kappa Alpha Psi, Alpha Phi Alpha, Omega Psi Phi • Haven House in Raleigh - We get referrals from them to mentor children. • StepUp Ministries - We get referrals from them to mentor children they determine are in need of our services. Through United Way, we are in a two-year collaboration with Boys & Girls Clubs and six other youth serving agencies h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. The funding we continue to receive from Orange County, Town of Chapel Hill, and Town of Carrboro is instrumental in helping cover our program costs. It costs about $1,500 to create and support a match, and that $1,500 is derived from: trained staff to enroll, interview, match and support mentoring relationships; trainings provided to parents and mentors; liability and property insurance; program activities; BBBSA affiliation dues; AIM fees; and criminal background checks for volunteers/mentors. Without your generous support, we would not be able to support matches, which means that even more at-risk youth in our community would "fall through the cracks." These children need positive role models to show them hope for a brighter future. Without grant funding, they simply will not have the opportunity to have a deep, meaningful relationship with one of our mentors. Our agency's mere existence hinges on the support of entities like Main Application 5/24/2016 8:51:19 AM .. g e 10 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION yours. We deeply appreciate your continued support and look forward to working together for many years in the future. Program/Project Information i) 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: ® Persons ❑ Households ❑ Units Program: Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 578 554 580 Female 490 471 492 Total 1068 1030 1072 Of the females, how many are single- female Head of Households (Omit for Human Services) 42% 45% 47% Ethnicity African-American 480 468 492 American Indian or Alaska Native 5 3 4 Asian 17 15 12 Caucasian 337 325 338 Native Hawaiian or other Pacific Islander 0 0 0 Other 229 219 225 Total 1068 1030 1072 Of the above, how many Hispanic/Latino 80 85 92 Of the above, how many non- Hispanic/Latino 149 134 225 Total 229 219 225 Main Application 5/24/2016 8:51:19 AM Pag e 11 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION Age 0-5 years 0 0 0 6-18 years 1068 1030 1072 19-50 years 0 0 0 51-61 years 0 0 0 62+ years 0 0 0 Total 1068 1030 1072 Geographic Location Durham City 359 348 356 Durham County 5 3 7 Carrboro 31 28 32 Chapel Hill 103 101 105 Chapel Hill Public Housing Residents Orange County 15 12 16 Raleigh 364 358 368 Wake County 191 180 188 Total 1068 1030 1072 Income Level —See following chart (Omit for HS) < 30%Area Median Income 31-50% Area Median Income 51-80% Area Median Income > 80%Area Median Income Total 0 0 0 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total 0 0 0 Main Application 5/24/2016 8:51:19 AM Pag e 12 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION CDBG & HOME ONLY- Area Benefit Activities (Infrastructure and Public Facilities) Street Census Tract Block Group Total Persons #LMI Persons 2015 Area Median Family income Limits U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Income 1 2 3 4 5 6 7 8 Level person people people people people people people people 30% AMI $14,150 $16,200 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 50% AMI $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500 80% AMI $37,750 $43,150 $48,550 $53,900 $58,250 $62,550 $66,850 $71,150 100% AMI $47,188 $53,938 $60,688 $67,375 $72,813 $78,188 $83,563 $88,937 115% AMI $54,266 $62,028 $69,791 $77,481 $83,734 $89,916 $96,097 $102,278 http://www.huduser.ord/portal/datasets/il/ill 5/FY2015 IL nc.pdf Main Application 5/24/2016 8:51:19 AM 0 I:° 13 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). If provided, indicate: Position Titles % (R) FTE* Actual Estimated Projected %Total *= Position * Program Retirement 2014-15 2015-16 2016-17 Budget Vacant Staff+ Plan (H) Health Plan CEO 1.00 45% $75,429 $75,429 $75,429 7% H Chief Development Officer 1.00 15% $72,000 $72,000 $72,000 6.5% H VP of Programs 1.00 100% $52,800 $52,800 $52,800 5% H VP of Partnerships 1.00 85% $49,315 $49,315 $49,315 4.7% H Finance/HR Manager .50 25% $36,100 $36,100 $36,100 3% H Director of Special Initiatives 1.00 100% $41,490 $41,490 $41,490 4% H Director of Site- Based Programs 1.00 100% $41,671 $41,671 $41,671 4% H Grants Coordinator .33 25% $25,000 $6,630 $6,630 Enrollment& Match Specialists 2.5 100% $85,000 $85,000 $85,000 8% H Customer Relations Specialist 1.0 100% $30,000 $30,000 $30,000 2% H Match Support Specialists 4.0 100% $152,000 $152,000 $152,000 14% H VOLUNTEER HOURS 22 95% $48,720 $50,280 $50,280 4.8% Main Application 5/24/2016 8:51:19 AM P 141 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 1,960 Main Application 5/24/2016 8:51:19 AM Pa e I 5 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO ❑ ® a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? ❑ ® b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? ❑ ® c) Current beneficiaries of the project/program for which funds are requested? ❑ ® d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. � r Signature: " 1/23/2016 Executive Director Date Signature: — 1/26/2016 Board Chairperson Date Main Application 5/24/2016 8:51:19 AM Pag e 16 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION m.) Work Statement This form is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. • Program Activities should outline major activities the agency implements to accomplish its program goals. • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. SMART Goals • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (The results and progress of all our activities and match relationships are recorded on our proprietary AIM (Agency Information Management) system, as managed and required by our national office and following all its guidelines.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. Main Application 5/24/2016 8:51:19 AM P of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected 2014-2015 2015-2016 2016-2017 BBBST staff carefully BBBST staff continues to BBBST staff will carefully screened, trained, carefully screen, trained, screen, train, match and matched and supported matched and supported support Bigs to ensure Bigs to ensure Bigs to ensure appropriate pairing of appropriate pairing of appropriate pairing of Bigs and Littles; Bigs and Littles; Bigs and Littles; establish match goals established match goals established match goals based on self-reported based on self-reported based on self-reported information from the information from the information from the program participants and Program Activity 1 program participants and program participants and any relevant external 1) BBBST will serve 850 children in Wake, Durham, and Orange Counties; 2) Average 1) BBBST will serve 1030 1) BBBST will serve 1060 match length for children in Wake, children in Wake, Community-Based Durham &Orange; Durham &Orange; Mentoring will remain at 2)Average Match Length 2)Average Match Length or exceed 24 months; 3) will remain or exceed 28 will remain or exceed 30 Average match length months for Community- months for Community- for School-Based based; 3) 22 months for based; 3) 25 months for Mentoring will remain at Site-based; 4) at least Site-based; 4) at least or exceed 22 months;4) 50% of our children will 52%of our children will 50% of children will report improved or report improved or report improvement in maintained socially maintained socially social acceptance; 5) 60% acceptance; 5) 60% of acceptance; 5) 65%of of children will report our children will report our children will report they improved or they improved or they improved or remained constant in remained constant in remained constant in their belief that missing their belief that skipping their belief that skipping school is a risky behavior school is a risky behavior school is a risky behavior Program Goals to avoid. to avoid. to avoid. Main Application 5/24/2016 8:51:19 AM 0 I:° 1 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/24/2016 8:51:19 AM 0 I:°' , 1 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION Agency/Program Big Brothers Big Sisters of the Triangle Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 128,650 $ 128,500 $ 130,500 2% Agency Generated Revenue (fees) 0 Local Government Grants: Orange County $ 2,000 $ 2,000 $ 6,000 200% Town of Chapel Hill $ 2,000 $ 2,000 $ 6,000 200% Town of Carrboro $ 1,350 $ 1,500 $ 3,000 100% Other Local: 0 Other Local: 0 Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 10,000 $ 10,000 $ 10,000 0% State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue $ 90,000 $ 90,000 $ 90,000 0% Please list 3 largest Mscellanous sources: ICAP Energy $ 30,000.00 Anonymous Foundation $ 60,000.00 Total Agency Revenue $ 234 000 $ 234 000 $ 245 500 5% AGENCY EXPENSES Compensation $ 213,500 $ 213,500 $ 225,000 5% Rent&Utilities 0 Supplies&Equipment $ 7,000 $ 7,000 $ 7,000 0% Travel&Training $ 6,000 $ 6,000 $ 6,000 0% Other Expenses: $ 7,500 $ 7,500 $ 7,500 0% Please list 3 largest"Other Expenses": Background Checks $ 3,000.00 Liability Insurance $ 4,500.00 Total Agency Expenses $ 234,000 $ 234,000 $ 245,500 5% SURPLUS/(DEFICIT)FOR PERIOD: Main Application 5/24/2016 8:51:19 AM Pag e 20 f 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it 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 $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Community and School-Based Mentorinq Cost Elements Cost($) Quantity/Unit of measure Subtotal ($) Enrollment Specialists $20 384 hours (32 hrs/mth x 12 mos) $7,680 Match Support Specialists $20 366 hours(30.5 hrs/mth X 12 mos) $7,320 Total $15,000 b.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program 234,000 234,000 245,500 Total # of Units 149 141 153 Cost Per Unit 1,570 1,659 1,604 Main Application 5/24/2016 8:51:19 AM P 21 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 5/24/2016 8:51:19 AM 0 I:° 22 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION c.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. Submit operating budget in your own format. We operate on a calendar year, so January 1st through December 31St Do not include funds that have been applied for but not yet awarded: If the total revenue is not the same amount as the budget for any fiscal year, please attach a statement explaining the deficit or surplus. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/24/2016 8:51:19 AM .. g e 23 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 258,235 $ 261,000 $ 285,000 9% Agency Generated Revenue(fees) $ 5,003 $ 6,000 $ 6,000 0% Local Government Grants: Orange County $ 2,000 $ 6,000 $ 6,000 0% Town of Chapel Hill $ 2,000 $ 6,000 $ 6,000 0% Town of Carrboro $ 1,500 $ 3,000 $ 3,000 0% Other Local: Town of Cary $ 3,000 $ 3,000 $ 3,000 0% Other Local: Durham County $ 15,000 $ 15,000 $ 15,000 0% Other Local: 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 56,093 $ 68,000 $ 68,000 0% State Govemment 0 Federal Government $ 75,000 $ 75,000 0% Other Grants:Private Foundations $ 203,000 $ 218,000 $ 218,000 0% Other Grants:BBBSA $ 1,451 $ 1,500 $ 1,500 0% Miscellaneous/Other Revenue $ 253,397 $ 260,000 $ 260,000 0% Rease list 3 largest Miscellanous sources: BFKS $ 89,240.00 Big Night Ball $ 144,903.00 Golf Tournament $ 19,254.00 Total Agency Revenue $ 800 678 $ 922 500 $ 946 500 3% AGENCY EXPENSES Compensation $ 630,742 $ 669,413 $ 680,000 2% Rent&Utilities $ 77,515 $ 80,000 $ 85,000 6% Supplies&Equipment $ 14,409 $ 32,000 $ 32,000 0% Travel&Training $ 6,714 $ 8,000 $ 9,000 13% Other Expenses: $ 107,627 $ 120,000 $ 125,000 4% Rease list 3 largest"Other Expenses": Fundraising Expenses $ 47,379.00 BBBSA dues $ 14,609.00 Audit $ 11,715.00 Total Agency Expenses $ 837,007 $ 909,413 $ 931,000 2% SURPLUS/(DEFICIT)FOR PERIOD: I$ (36,329)1 $ 13,087 I$ 15,500 I 18% Main Application 5/24/2016 8:51:19 AM Fag 24 of 25 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 it A continued Provider's Outside Agency Application MAIN APPLICATION Main Application 5/24/2016 8:51:19 AM .. e 2 5 o of 2 5 DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Big Brothers Big Sisters of the Triangle, Inc. Funding Award: $4,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel Salaries,FICA, and Fringe 4,000 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. • Big Brothers Big Sisters of the Traingle (BBBST) staff will carefully screen, train, match and support Bigs to ensure appropriate pairing of Bigs and Littles; establish match goals based on self-reported information from the program particiapnts and any relevant external resources (e.g., counselor/therapist, references, former volunteer experience). BBBST staff also will provide supplemental activities, trainings, and opportunities for all program participants. 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 BBBST will serve children in Wake,Durham,and Orange 1060 people Community Based Match Length 30 months Site based Match Length 25 months Children will report improved or maintained socially acceptance 52% Children will report they improved or remained constant in their belief that skipping schools is 65 % a risky behavior to aviod DocuSigned by:::�II IIAA bru- "u"' 11/11/2016 Certified by: Title: CEO Date: y SE4774DA58354D3 (Provider's Signature) DocuSign Envelope ID:99BDCA4A-2934-455A-8D45-0C865AD016D0 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/17/2016 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 Debbie Callahan Moore and Johnson Agency PHONE 919-582-1977 FAX 919-719-8806 3809 Computer Drive (A/C,No,Ext): (A/C,No): Raleigh NC 27609 ADDRESS:dcallahan @mooreandjohnson.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Berkshire Hathaway INSURED BIGBR-1 INSURER B:Summit Holdings Big Brothers Big Sisters of the INSURER C: Triangle, Inc. 808 Aviation Pkwy Ste 900 INSURER D: Morrisville NC 27560 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 884394368 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER LIMITS (MM/DD/YYYY) (MM/DD/YYYY) A x COMMERCIAL GENERAL LIABILITY 47-SPK-255375-01 9/28/2016 9/28/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $1,000,000 X Employee Benefit MED EXP(Any one person) $20,000 X D&O Liability 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: Empl.Benefits $1,000,000 A AUTOMOBILE LIABILITY 47-RWS-255376-01 9/28/2016 9/28/2017 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 ANY AUTO BODILY INJURY(Per person) $ AUT OWNED SSCHOEDULED BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION 0521063508 9/8/2016 9/8/2017 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 A Property 47-SPK-255375-01 9/28/2016 9/28/2017 Blkt BPP $200,000 Crime Fidelity $100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Professional Liability #47-SPK--255375--01 9/28/16 to 9/28/17 Limits $1,000,000/$3,000,000 Aggregate Abuse and Molestation $1,000,00 Each Incident/ $1,000,000 Aggregate CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Government Finance&Admin Services THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough NC 27278 AUTHORIZED REPRESENTATIVE u LOA\ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD