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Home My WebLink About2016-647-E Finance - TABLE - Outside Agency Performance Agreement DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 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 TABLE, a not-for-profit corporation, located at 205 West Weaver Street, Carrboro,NC 27510 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and TABLE 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 5000. 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 $1,250. 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. (TABLE) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 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. (TABLE) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 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. (TABLE) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 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 TABLE 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: (TABLE) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 County: Finance &Administrative Services Provider: TABLE Orange County 205 West Weaver Street Post Office Box 8181 Carrboro,NC 27510 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. E a and the Provider S ew trim S 11/10/2016 1 A75RQ7D E6QACF Date Llj For and o Cirange County, Government bbl,in,lt' NuitAMt-rS(,t ti 11/11/2016 ru 17QQaa79 F477 Bonnie Hammersley, County Manager Date (TABLE) Orange County Outside Agency Per/onnance Agreement Rev. 8/16 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 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: a4&.6 1 vw u s Certified by: 1A75892D6E604CE... Title: Executive Di rector Date: 11/10/2016 (Provider's Signature) (TABLE) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency TABLE, Inc. Date/Time Complete Y/N Program(s) Weekend Meal Backpack Program Section For CDBG & HOME - Subsection HUD Regulations 1. Cover Page I a. 1 Applicant Contact Information b. lo 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. i1 Agency's Purpose/Mission 570.507, 570.610; 24 CFR Parts 84 or 85 c. Z1 Agency's Types of Services Provided d. Agency's Experience e II Other Pertinent Information 3. Program/ a. 1 Type of Application and Program Identified 24 CFR 570.200(a), Project b. 1 Summary of Program 570.201-570 208, Information - 507,503 c. 11 Description of Identified Need (for each d. kh Description of Population to be Served program/ e. 1 4 Activity Manager and Location Description project for which funding f. Activity Implementation Timeline is requested) g' I, Agency Collaboration h. El Describe Impact of Reduced/No Allocation i. Other Pertinent Information j. Complete Target Population/Beneficiary Chart k. Complete Schedule of Positions L 1i4 Signed Conflict of Interest Disclosure m. r Complete Work Statement I e DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION 24 CFR 570.200(a), 4. Financial (for Program Budget Worksheet and Detail should reflect 570.201-570. 208, each expenses for the entire program and ALL sources of 507.503 program! funding. 24 CFR 570.506, project for 570.507, 570.601, which funding a. Program Budget Worksheet 570.602, 570 607(b), is requested) b. Program Budget Detail 570.611 24 CFR c. Cost Per Unit 570.502-570.504, d. Agency Operating Budget Worksheet 570.506, 570.507, 570.610; 24 CFR Parts 84 or 85, and OMB Circulars A-87 or A 122; Treasury Circular 1075 5. Supplemental A. [7] Part A: CDBG & HOME Sections (as B. E Part B: Construction/Rehab applicable) 6. Attachments a. 4 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. Z. IRS Federal Form 990 c. Z NC Solicitation License d. IRS Federal Tax-Exemption Letter e. Z Certificate of Insurance f. 1 List of Board of Directors 24 CFR Parts 84 or 85 g. 4, Articles of Incorporation/Bylaws 24 CFR 570.208, h. A Authorization to Request Funds 570.500(c), 570.611 i. Z Authorized official designation j. 4 Solid Waste Program Fee (SWPF) Verification Main Application 1/25/2016 11:34:49 AM ' ( DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application-7j a) Applicant Contact Information Applicant Organization's Legal Name: TABLE Ministries, Inc. Applicant Organization's Physical Address: 205 W. Weaver Street, Carrboro, NC 27510 Applicant Organization's Mailing Address: 205 W. Weaver Street, Carrboro, NC 27510 Applicant Organization's Web Address: www.tablenc.orq Executive Director: Ashton C. Tippins Telephone Number: (919)636-4860 E-Mail: tablencgmail.com DUNS Number: N/A (Dun & Bradstreet, lric, provides this number at no charge, and it is required for Federal funding recipients.) b) Proiect/Proqram Contact Information Project/Program Name: Weekend Meal Backpack Program Project/Program Primary Contact and Title: Ashton Tippins Telephone Number: (919)636-4860 E-Mail: tablencgmail.com c) Funding Request Identification Total Project/Program Cost: $224,088 Total Amount of Funds Requested: $30,000 Proposed Use of Funds Requested (2-3 Line Maximum): We respectfully request $30,000 for the purchase of food, partial payment of program staff, and assistance with rental of new space and equipment. 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. E CDBG Non-Construction (CH) $ Grant [11 Loan LI CDBG Construction (CH) E Grant Eli Loan Li) HOME CHDO (00) Grant ri Loan E HOME Other(OC) E Grant El Loan Human Services: Carrboro $10,000 14 Chapel Hill $10,000 Orange County $10,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: ft, C. ' III Ulf Executive Director Date Signature: &it 64///1-- 4hINy1,/L 1/ I(71(0 Board Chairperson Date Main Application 1/11/2016 12:10:18 PM P (; 3 o If 1 6 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION 2. AGENCY INFORMATION Please provide the following information about your agency (Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Month/Year) b) Agency's Purpose/Mission c) Types of Services the Agency Provides d) Agency's Experience with Similar Programs as the Funding Request e) Other Pertinent Agency Information Main Application 1/25/2016 11:34:49 AM P (i (,` 4 of 21 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application oyepr,„e,,, ,2pJ„,y,..apigrov, ! TABLE feeding local hungry kids Agency Information What is T Joy Mac Vane and several UNC students founded TABLE in November 2007 (incorporated on the 21st). Our founders recognized the prevalence of hungry children in the Chapel Hill-Carrboro area and noticed that there were no food assistance services for children. Our Mission is to bring together UNC college students and local community members to feed hungry children in Chapel Hill and Carrboro. TABLE has three goals: to provide weekly emergency food aid to local hungry children, to educate and expose our little ones to healthy foods and eating habits, and increase community awareness of local childhood hunger. TABLE is a 501(c)(3) non-profit organization that began feeding 12 local elementary school children in 2008 and has since expanded to provide healthy food to 500 children each week. TABLE has four programs to support its mission and goals: 1) The Weekend Meal Backpack Program provides healthy non-perishables, local fresh produce and fresh milk to Children that are at risk of hunger on weekends and school holidays; 2) Snack Chef exposes our children to fresh foods and teaches them how to make easy, healthy snacks at home; 3) Summer TABLE provides healthy food to local kids for 8 weeks in the summer months; 4) TABLE On the Go (our newest program) allows children the opportunity to visit local farms, farmer's markets, and community gardens so they may learn about healthy food, their community, and where their food comes from. While there are a number of wonderful hunger-relief non-profits in the area - IFC, PORCH, Heavenly Groceries, Meals on Wheels, etc, TABLE is the only organization to deliver healthy food directly into the hands of our community's children. We admire and respect each of these organizations and recognize the gap they fill in the community. We collaborate with many of them in various ways. We provide food that is inappropriate for our kids to IFC and Heavenly Groceries (such as expired foods within 1 year, glass spaghetti sauce, or cornmeal). While Meals on Wheels has a significantly different Mission than that of TABLE, we have had some discussions regarding the possibility of sharing space. We have also had a number of conversations with PORCH about how we can collaborate with one another. Currently, both PORCH and TABLE work through school social workers who can identify which children have families that receive monthly bags of food from PORCH and which children carry home weekly bags of food from TABLE. Additionally, we are in the early stages of working with each of these organizations to put an end to summer hunger in Chapel Hill and Carrboro with Mayor Fiemminger and others. DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Weekend Meal Backpack Program As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: Human Services (Main Application Only) LI CDBG Non-Construction — (Main Application AND Part A) CDBG Construction — (Main Application AND Part A AND Part B) FT HOME CHDO Set-aside — (Main Application AND Part A) HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Disabled Public Housing Program Category Youth Adult Elderly (not elderly) Neighborhoods/Residents Education Health and Nutrition X Job Training_ Sports and Arts Activities Pre-School Activities After-School Activities Mentorin. Transportation Housin. Other: Please specify Program/Project Description (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/project: b) Summarize the program services proposed and how the program will address the chosen Town/County priority? 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. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. e) Who specifically will carry out the activities and in what location will they be carried out? Main Application 1/25/2016 11:34:49 AM Poge 5 c) 2 1 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application Program/Project Description Summarize the program services proposed and how the program will address the chosen Town/County priority? The Weekend Meal Backpack Program (WMBP) is TABLE's school year hunger relief program for hungry children living in Chapel Hill and Carrboro, NC. Currently, 30% of kids in the Chapel Hill- Carrboro School System rely on free and subsidized school breakfasts and lunches during the week. Consequently, they often go hungry on weekends and school vacations when those free meals are not available. TABLE works to meet their need for emergency food during those times. At the end of each week, TA LE distributes fresh produce and healthy non-perishables to participating youngsters. Receiving,this emergency food aid each week allows children to return to school Mondays not ravenous -but ready to learn. TABLE's Weekend Meal Backpack Program primarily addresses the Town/County priority to improve health, and nutrition of local kids by providing them with healthy non-perishables, produce, and fresh milk every single week. Please see our goals for statistical information regarding the Weekend Meal Backpack Program's impact on hunger and nutrition. Secondarily, however, it is evident that the Weekend Meal Backpack Program directly addresses the other two Town/County priorities as well: 1) 'WMBP improves the opportunity for a good education for local kids because they are able to focus on their schoolwork instead of their grumbling bellies as well as miss fewer school days because of frequent sickness and 2) WMBP serves as a safety-net for parents and families of children because it allows parents to put more of their funds toward other bills like rent, utilities, fuel or transportation, keeping them from falling further into poverty. 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. TABLE's hunger relief programs target food-insecure preschool, elementary, and middle school. children living in Chapel Hill and Carrboro, NC. During the 2014/2015 school year, the Chapel Hill- Carrboro School System let us know that 30% of children attending their schools were enrolled in the National School Lunch Program suggesting that 1 in 3 local children are 1) at risk for hunger on weekends and other times of the year when schools meals are not available and 2) have limited access to fresh food because of expense and access issues. The breakdown of this statistic is as follows: • 72.58% of preschool children. • 30.14% of elementary school children • 24.89% of middle school students That's more than 2,553 kids that are likely going hungry on weekends and school holidays when they do not have access to their free school breakfasts and lunches. These kids are not simply at risk for being hungry on weekends, but they are at risk for low academic performance, inappropriate behavior, low self-esteem, and health problems. Kids cannot grow up to be successful, productive adults under these conditions. They MUST have their basic needs fulfilled before they even stand a chance of performing well in school, behaving appropriately, having strong DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application relationships, and strong, healthy bodies. The growth, prosperity, and success of our towns and county depend fully on the growth and success of our children. Describe the population to be served or the area to benefit and indicate how you will identify beneficiaries. TABLE provides healthy food every week to preschool, elementary, and middle school children living in Chapel Hill and Carrboro. All children participating in our hunger relief programs live in local low- income communities. About 97% of the children we serve represent racial and ethnic minority populations. To reach local needy children, TABLE partners with 25 community organizations to provide healthy food to those kids through the Weekend Meal Backpack Program. TABLE identifies the beneficiaries of our program by partnering with staff and faculty at our numerous partner locations. School social workers and after school staff help us identify children arid families that are in need as well as distribute and gather permission forms. At the low-income housing facilities, our staff and volunteers walk door-to-door to offer our services. At all of our locations, parents simply need to fill out a permission form for their child to receive healthy food every single week. Who specifically will carry out the activities and in what location will they be carried out? TABLE Staff, Volunteers, and Partners will carry out the activities necessary to provide healthy food to local children. The storage and preparation of bags of food for kids will be carried out at TABLES Office/Warehouse at 205 W. Weaver St., Carrboro, NC 27510. Bags of food will be delivered to kids all over Chapel Hill and Carrboro. See a list of our partners below. 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. Activities for the Weekend Meal Backpack Program will be carried out from mid-September 2016 until the first week of June 2017. We will be delivering bags of healthy food to kids at their school, after school center, or low-income apartment home every single week. This program has been in existence for 8 years. We begin reaching out to new and current partner agencies in early September. By mid-Septm.ber we make our first delivery. We continue to add new children to our roster and increase the number of children served throughout fall programming. Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. • McDougle Elementary School: Provide information/support to feed attending kids. • Frank Porter Graham Elementary School: Provide information/support to feed attending kids. • Ephesus Elementary School: Provide information/support to feed attending kids. • Estes Hills Elementary School: Provide information/support to feed attending kids. • Mary Scroggs Elementary School: Provide information/support to feed attending kids. • Rashkis Elementary School: Provide information/support to feed attending kids. • Seawell Elementary School: Provide information/support to feed attending kids. DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application • Communities in Schools at McDougle Middle School: Provide information/support to feed attending kids. • Communities in Schools at Culbreth Middle School: Provide information/support to feed attending kids. • Communities in Schools at Phillips Middle School: Provide information/support to feed attending kids.. • Communities in. Schools at Smith Middle School: Provide information/support to feed attending kids. • Dobbins Hill Family Resource Center: Provide information/support to feed attending kids. • Town of Chapel Hill (Public Housing Facilities): Provide information/support to feed attending kids. • El Centro Hispano: Provide information/support to feed attending kids. • Hargraves Community Center: Provide information/support to feed attending kids. • Communiversity: Provide information/support to feed attending kids. • Rogers-Eubanks Neighborhood Association: Provide information/support to feed attending kids.. • Maple View Farms: Donate fresh milk every week to kids through WMBP. Also partnered to create a field trip opportunity for our kids. • Farmer Foodshare: Partner to provide purchased and donated fresh food to kids via WMBP. • Weaver Street Market: Help us raise funds/food for programs. Provide services for TABLE to purchase food for WMBP. Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Currently, TABLE has at least 30 children on a waitlist. These children and their parents have requested TABLE's services, but we are unable to provide them with healthy food every week because we have reached space, staff, and financial capacity. Once we commit to a child, we ensure that child can receive a bag of food every single week until/unless that bag becomes unnecessary or they have graduated from middle school. If TABLE does not receive funding from the Towns and County, we may not be able to increase our capacity and serve additional children on our waitlist. Include any other pertinent information. As progressive as our communities are, it is not permissible for even one child to go hungry when we have the resources that we do. How can we expect a child to perform well in school, relationships, and life if we are not providing them with the healthy food that they need? If we want our Towns and community members to flourish, then we need to start ensuring that our kids have their basic needs met. TABLE's long-term plan is to provide healthy food to every single child in Chapel Hill-Carrboro that is hungry. Afterwards, we would love to focus on provide and/or partnering with other organizations to provide the children in Hillsborough, Mebane, Efland, and other surrounding communities with the healthy food they need. It is not that Chapel Hill and Carrboro are more important, it is simply all that TABLE can handle at the moment. These two Orange County cities are a huge undertaking, yet, we can stop childhood hunger here. Please standing alongside TABLE to provide healthy food to our community's children. We appreciate your consideration. DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION 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. g) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specific examples of the coordinated/collaborative efforts. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. i) Include any other pertinent information. Program/Project Information j) Complete the Target Population and Program Beneficiary Demographics Chart k) Complete the Schedule of Positions Chart for Program Staff I) Disclosure of Potential Conflicts of Interested must be signed m) Complete the Work Statement Chart to describe the work to be performed, and be sure to attach copies of all data collection tools that will be used to verify achievement of program goals and objectives. Describe who will be responsible for monitoring progress. Information to Com•lete 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 LActual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 49% 49% 49% Female 51% 51% 50% Total' 100% 100% 100% Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 40% 40% 40% American Indian or Alaska Native -- -- Asian 17% 19% 20% Caucasian 3% 5% I 5% Native Hawaiian or other Pacific Islander -- -- Other 40% 35% I 34% Total 100% 1 100% 100% Main Application 1/25/2016 11:34:49 AM ') ( 6 () 2 1 DocuSign Envelope ID:B32F3E9 3514F2E575e [ /\- continued Provider's Outside Agency Application MAIN APPLICATION Of the above, how many Hispanic/Latino 9,5% 15% 18% Of the abmve, how many non' Hiapanio/Latino 90,5Y6 85% 82% _____ Total 100Y6 10094 100%_ Age 0-5 years 296 6�� 10%�0 ------ — ----T -- 6'18 years 98% I 95% 90% 19-50 years -- — 51-01 years -- �- — 62+ years — Total 100Y6 �O096 100% Geographic location estimated for Geographic Location 2014-2015 Durham City <1% <196 I <1% Durham County -- <1`)/0,� I �__�� Carrboro 25% 2096 22% Chapel Hill 55% 52% 48% Chapel Hill Public Housing Residents 19% 25% Orange County <1% . <1Y4 Raleigh I -- -- Wake County <196 | �1�� <1% Total 100% � 100Y4 I 100% Income Leve —See following chart (Omit for HS) 1. < 3096 Area Median Income �-------- i 31-50% Area Median Income 51'8O96 Area Median Vnonme > 80% Area Median Income Total ' 0 0 0 Special Needs (Omit for HS) Elderly (Over 62) |- / ---------- Disabled (not elderly) Homeless People with HUV/Aids � � Total 0 I 0 0 Main Application 1/25/2016 11:34:49 AM 1 r) 2 I DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION CDBG & HOME ONLY - Area Benefit Activities (Infrastructure and Public Facilities) Street Census Tract Block Grou• 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°/0 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.ordiportal/datasets/iI/i115/FY2015 IL nc.pdf Main Application 1/25/2016 11 :34:49 AM 1-) r (jc 8 o t 21 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions: these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). I If provided, 1 %Total indicate: Position Titles % Budget (R) FTE* Actual Estimated Program Projected * = Position .a.,,r",(1 * 2014-15 2015-16 2016-17 Retirement Vacant Staff+ on `201:) I Plan ,2016 (H) Health Plan $2,000 health Executive Director 1.00 50% $41,450 $43,574 $44,941 9,4% stipend 1 1 1 Program Director 1.00 100% $30,667 $31,465 $32,409 6.8% -- 1 Community 1 $4,508 Outreach (hired Coordinator .50 25% 2/2015 $14,616 $15,054 3.2% -- 1 Project Specialist :25 25% ' $8,436 $9,744 $10,036 2.1% -- 1 1 PD Assistant ,50 100% $0 $0 ' $14,616 1 N/A 1 -- 1 7 Interns .12 75% $0 $0 $0 0 -- 12 Team Leaders .03 1 100% $0 $0 $0 0 -- Operations Manager .11 100% 1 $0 $0 $0 0 1 -- 2 Volunteer Event 1 1 Coordinators .03 1 25% $0 $0 $0 0 -- _.. 2 Graphic Designers .03 25% $0 $0 $0 0 -- 80 Weekly Shift I Volunteers .04 100% $0 $0 $0 0 1 -- Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00, half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 1,960 Main Application 1/25/2016 11:34:49 AM P r-1 j (J 9 o 1 2 1 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 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 Eg a)Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? Li b)Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? LII 121 c) Current beneficiaries of the project/program for which funds are requested? 0 •4 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 bel. To the best of my knowledge and belief all of the above info ation 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. Signature: ft v i.,* 1911111 Executive •irector Oat Signature: Wil - 411 ' 1/20/1/0 Board Ch l rperson Date Main Application 1/19/2016 11:43:02 AM Page 11 of 1 9 DocuSign Envelope ID:B32F3E9 3514F2E575e [ /\- 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 progranl, you will only document the projected information. • Program Activities should outline major activities the agency implements to accomplish its program goals. • Program Goal should explain' what the program is trying to achieve/accomplish, Goals are statements about what the program should accomplish. „SMART Goals • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. Actual Estimated P rojected 2D14 ��1� 2015-2016 �O1G ��17 ' - ' Partner with local Partner with local Partner with local schools, after school schools, after school schools, after school centers, non-profits, centers, non-profits, centers, non-profits, Town Housing Town Housing Town Housing Departments, etc. to Departments, etc. to Departments, etc to provide food weekly to provide food weekly to | provide food weekly to local kids through our local kids through our local kids through our Weekend Meal Weekend Meal Weekend Meal Program Activity 1 1 Backpack P Backpack Program. Backpack Program. Provide up to 400 kids Provide up to 500 kids Provide up to 600 kids with healthy food at with healthy food at with healthy food at least 34 weeks of the least 34 weeks of the least 40 weeks of the Program Goal year year year TABLE maintains a TABLE maintains a TABLE maintains a Current Numbers Sheet Current Numbers Sheet Current Numbers Sheet of children we serve of children we serve of children we serve every single week. We every single week. We every single week. We will use this to will use this to will use this to determine how many determine how many determine how many Performance Measures kids are served. kidoaresen/ed� � kids are served. ------ -- -- ---- VVenoetourgoa| of We hope to meet our We met our goal in serving 500 kids in goal by December Program Results February 2015. October 2015 2016. - ' --- ---------- Main Application 1/25/2016 11:34:49 AM P @ c; 8 1 2 0 f 2 1 DocuSign Envelope ID:B32F3E9 3514F2E575e [ /\- continued Provider's Outside Agency Application MAIN APPLICATION Partner with Farmer Partner with Farmer Partner with Farmer Food Share, local farms, Food Share, local farms, 1 Food Share, local farms, and other businesses to and other businesses to I and other businesses to I purchase and receive I purchase and receive purchase and receive donations of fresh donations of fresh donations of fresh produce and milk for produce and milk for I produce and milk for our Weekend Meal our Weekend Meal our Weekend Meal' Program Activity 2 Backpack Pro m � Backpack Program � Backpack Program � -- |-- --- ---- -- Provide healthy food to Provide healthy food to Provide healthy food to kids we serve by | kids we serve by kids we serve by distributing bags that distributing bags that distributing bags that include 30 percent include 33 percent I include 36 percent Program Goal produce and fresh mi|k� produce and fresh milk. and fresh milk, We track all food that We track all food that We track all food that we distributed by we distributed by we distributed by weight. To measure this weight. To measure this weight. To measure this goal, we simply have to goal, we simply have to goal, we simply have to compare the total I compare the total compare the total weights of the produce weights of the produce weights of the produce and milk with the total and milk with the total and milk with the total weight of all bags weight of all bags weight of all bags Performance distributed � distributed distributed Produce and milk mad'e up 32%of everything we distributed through � > our Weekend Meal I Currently, we' Program Re lto 8 ac k k Program surpassing th|sgoa|. N/A � _ Provide Provide nutrhiowsfoods Provide nutritious foods thatkidsmeedevery that kids need every that kids need every week as well as week as well week' reinforce health and reinforce health and reinforce health and academic habits using academic habits using academic habits using our Food for Thought our Food for Thought � our Food for Thought Worksheets (academic Worksheets (academic Worksheets (academic and nutrition education I and nutrition education and nutrition education I 1 worksheets that go worksheets that go worksheets that go home monthly in' the home monthly in the home monthly in the p bags �a ffmod), bags of food) . Main Application 1/25/2016 11:34:49 /\M P r, | 2 � DocuSign Envelope ID:B32F3E9 3514F2E575e [ /\- continued Provider's Outside Agency Application MAIN APPLICATION 25% of kids experience 25%of kids experience 30% of kids experience � ( some other academic, some other academic, some other academic, health, personal, health, personal, health, personal, physica[ orsoc�| physical, or social physical, or social � bcncfitasaresultof benefit as a result of benefit as a result of receiving the nutrition receiving the nutrition receiving the nutrition Program Goal they need every week I they need every week. they need every week TABLE executes surveys TABLE executes surveys TABLE executes surveys every spring with every spring with every spring with parents of children that parents of children that parents of children that Performance Measures TABLE TABLE serves TABLE serves | � Out of a small pool of | � parents surveyed, 35.7Y6ofparents expressed that their child was exhibiting positive social behavior, better 8rade� orsome otherbenefit (|ike � > appreciation of food, I love of cooking, feeling � | of etc.) � We to importance, ' expect because of the child's exceed our goal of 25% participation in the of kids receiving some | / Weekend Meal | other benefit. We plan Backpack Program. 6% to expand and � | of these same parent randomize our pool of saythattheirchi|d likes parents asweUas more healthy foods OR implement any is more willing to try feedback we receive Program Results new foods. from them. N Main Application 1/25/2016 11:34:49 AM DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Ex g lanations about Pro g ram Finances: Our Supplies and Equipment expenses nearly doubled from FY 2014-2015 to FY 2015-2016 because our program needs nearly doubled. In November 2014 we began feeding 300 children and in February 2015, we began feeding 400 children. For FY 2015-2016, we began feeding 500 kids in early October 2015. We expect our rent/utilities and salaries to increase over the next couple of fiscal years as we plan to continue to ramp up our programs, evaluate their impact, and continue to make improvements to make the most impact on our kids. Main Application 1/25/2016 11:34:49 AM P ,) o 1 5 of 71 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 341,113 $ 457,329 $ 496,285 9% Agency Generated Revenue (fees) 0 Local Government Grants: Orange County $ $ $ 10,000 Town of Chapel Hill S $ 2,000 $ 10,000 400% Town of Carrboro $ 2,000 $ 10,000 400% Other Local: 0 Other Local: 0' Other Local: Ft tmre than 3 SOUrces,please provide a separate list Nom-Local Government Grants im Mangle United Way 0 State Gowirnment 0 Federal Government 0 Other Grants Other Grants 0 MiscellaneouslOther Revenue 0 Please list 3 largest Miscellanous sources Total Agency Revenue $ 341 113 $ 461 329 14%l AGENCY EXPENSES Compensation $ 55,628 $ 60,342 $ 76,769 27% Rent&Utilities $ 32,864 $ 41,235 $ 46,100 12% Supplies&Equipment $ 119,357 $ 232,774 I $ 260,029 12% Travel &Training S 973 $ 1,450 $ 1,600 107 1 Other Expenses: $ 1,350 $ 1,269 $ 30'i Ftlease.list 3 largest"Other Expenses" 50% Website/IT Sen/ices $ 1,350.00 ' Total Agency Expenses $ 210 172 $ 337 061 $ 388 798 14%1 SURPLUSt(DEFICtlT)FOR PERIOD: [ 130,941 $ 124,268 $ 140,487 133(, Main Applicafion 1/25/2016 11:34:49 AM Page 16 o f 2 1 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION b.) Program Budget Detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Example Program: Credit Counseling Class Cost Elements Cost($) Quantity/Unit of Measure Subtotal ($) Credit Counseling Teacher–in class $25 I 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 1 $20 120 hours (10 hrs/mth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: 2015-2016 Weekend Meal Backpack Program Cost Elements Cost($) Quantity/Unit of measure Subtotal_($) Food $1.69/1b 500 kids x 33 weeks x1.69/1b x 8 223,080 lbs food Supplies (paper, sharpies, laundry bins, $230 $230 in various supplies x 12 2770 shelves, scales, etc.)– used for dating, I months distribution, and tracking of food, Vehicle Maintenance (fuel, taxes, title, $577 $577/month for 12 months for 2 6,924 insurance, etc) vehicles I Program Director $2,622 $2,622/month for 12 months $31,465 Space Various I ($2,400 rent x 8 months for $41,235 1,106sgft) = 19,200 + ($3,500 rent x 4 months for 3,000sgft) = 14,000 + Utilities at an average of 670/month for 12 months) =$8,035 $19,200 + $14,000 + $8,035 50% Executive Director(grants, $1,899 $1,899/month for 12 months $22,787 consultation, program planning, etc) IT Services for Program Record Keeping $105 $105/month for 12 months $1 260 I Other Staff $508 $508/month for 12 months for 2 $6,090 part-time staff members Main Application 1/25/2016 11 :34:49 AM a 1 1B n DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION 1 1 I Travel/Mileage Reimbursement for food $125 $125/quarter for all mileage $500 pick-ups and deliveries reimbursement and travel Training, consultation, meetings, etc. $79 I $79/month for various training - 11 $950 Board Meetings, official training, consultation etc Total $337, 061 C.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $223,195 1 $337,061 $385,798 Total # of Units 12,500 1 16,500, 21,000 Cost Per Unit 17.86 $20.43 $18.37 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 1/25/2016 11 :34:49 AM I' DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION d.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017, It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Explanations about Agency Finances: As explained above about our program expenses, our Supplies and Equipment expenses nearly doubled from FY 2014-2015 to FY 2015-2016 because our program needs nearly doubled. In November 2014 we began feeding 300 children and in February 2015, we began feeding 400 children. For FY 2015-2016, we began feeding 500 kids in early October 2015. We expect our rent/utilities and salaries to increase over the next couple of fiscal years as we plan to continue to ramp up our programs, evaluate their impact, and continue to make improvements to make the most impact on our kids. Main Application 1/25/2016 11:34:49 AM P I q 20 ci 21 DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 t A- continued Provider's Outside Agency Application MAIN APPLICATION AGENCY NAME: Actual Estimated Projected Percent AGENCY REVENUE 2014.15 2015.16 2016.17 Chan e Private Donations MN= 5 496,285 Agency Generated Revenue(fees) 111111111111111111111111 0 Local Government Grants: Orange County $ $ tl $ 10,000 0 Town of Chapel Hitll $ $ 2,000 $ 10,000 400% Town of Carrboro • III . 10,000 400% Other Local 0 Other Local 1111.111111101.11111111111111111111111.111 Other Locatl: 1111111.111111111111111111111.11111111111111111111111 •1 If were than 3 sources,please provide a separate hst Non-Local Government Grants Triangtle United Way 11111111111.11111111111111111101111111111 01 State Government 11111111111111111111111111111111111111110111111111M Federal rill I. 1110.11.11 0 Other Grants 11.11111111111.11.011111111.11111110. 0 Other Grants. 111.11111111111111111.111111111111111111. 0 Miscellaneous/Other Revenue 0 Please list 3 largest Mecellaneus sources $ - Total Agency Revenue PIENVIEFINggiallin AGENCY EXPENSES Compensation S $ 101,399 $ 119,056 .11E1 Rent&Utilities $ 46,100 Supplies&Equipment $ 296,029 1=111= Travel&Training $ 1,45• $ 1,600 10% Other Expenses: 24,500 Please list 3 largest"Other Fxpenses" COntrad Services $ 9,780 00 Payroll $ 7,765 00 Insurance $ 3,37'8 00 Total Agency Expenses $ 307 098 SURPLUS/(DEFICIT)FOR PERVOD: $ 34,015 $ _21 Main Application 1/25/2016 11:34:49 AM Paqu 21 of DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: TABLE Funding Award: $5,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel—Salaries 5,000 Programmatic Supplies—Food Rental assistance 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. • Partner with local schools,after school centers, non-profits, Town Housing departments, etc to provide food weekly to local kids through our weekend meal backpack program. • Partner with Fanner FoodShare, local farms, and other businessess to purchase and receive donations of fresh produce and milk for our weekend meal Backpack program. • Provide nutritious foods that kids need every week as well as reinforce health and academic habits using Food for Thought worksheets. 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 Provide kids with healthy food 600 kids/ 40 weeks. Percentage of food bags that include produce and fresh milks 36% Percentage of kids that experience academic,health,personal,or social benefit as a result of 30% receiving the nutrition they need each week. DocuSigned by: slew fippiws Executive Di rector 11/10/2016 Certified by: q,�Rq,�E6 acp Title: Date: (Provider's Signature) DocuSign Envelope ID:B32F3E9F-996A-4000-8CAF-83514F2E5759 AI;°RD CERTIFICATE OF LIABILITY INSURANCE D09h6/2016 I 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 ALLAN GRAY CONTACT NAME: ALLAN GRAY PHONE [INC,FAX 1208 RALEIGH RD INC.No,Exti•919-968-0470 No):919-968-8414 StateFerm CHAPEL HILL, NC 27517 ADDRESS:Allan. rg ay.cnjzt statefarm,com INSURER(S)AFFORDING COVERAGE NAIL# _INSURER A:State Farm Fire and Casualty Company 25143 INSURED Table Ministries, Inc. INSURERS: 205 West Weaver Street INSURER C: W � Carrboro, NC 27510 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTIMTHSTANDING 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 I TYPE OF INSURANCE ADOL SUER POLICY EFF I POLICY EXP LIMITS LTR _INSR. WVO POLICY NUMBER IMM/DOMYYY)'(MMIBDIYYYYI A i GENERAL LIABILITY 93-BC-Al 58-3 02106/2016 02/06/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIAEILITY PREMISES(Ea occurrence) $ 300,000 CLAIMS-MADE X I OCCUR MED EXP(Any one person) S 5,000 I PERSONAL.&ACV INJURY 5 1,000,000 I GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER, PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY 'ER,° LOC i $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E iEa ccident) $ ANY AUTO I BODILY INJURY(Per person) $ ALL OWNED SCHEDULED I BODILY INJURY(Per accident) $ AUTOS , AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) - $ -. UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ J DED I RETENTIONS $ WORKERS COMPENSATION WC STATU- 'OTH- AND EMPLOYERS'LIABILITY Y!N TORY LIMITS I ER ANY PROPRIETOR/PARTNER/EXECUTIVE N 7 A E.L.EACH ACCIDENT $ OFFICE/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ II yes,describe under E,L.DISEASE,POLICY LIMIT $ DESCRIPTION N OF OPERATIONS below Imo-�. T DESCRIPTION OF OPERATIONS!LOCATIONS f VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space Is required) CERTIFICATE HOLDER CANCELLATION ANY OF Orange County Government THE SHOULD DESCRIBED VTHEREOF, NOTICE I WILL BE BE CANCELLED DELIVERED BEFORE IN CIO Allan Coleman ACCORDANCE WITH THE POLICY PROVISIONS, 200 S.Cameron St. ;' R AUTHORIZED REPRESENTATIVE f Hillsborough, NC 27278 /, ,/Ad. I ,. O 1988-2010 ACORD C ORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD 1001486 132849.8 01-23-2013