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2016-666-E Finance - Rogers-Eubanks Neighborhood Association - Outside Agency Performance Agreement
DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 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 Rogers-Eubanks Neighborhood Association, a not- for-profit corporation, located at 101 Edgar Street, Chapel Hill,NC 27516("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Rogers-Eubanks Neighborhood Association 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 20000. b. All funds appropriated shall be used for purposes described in Exhibit A. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $5,000. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Rogers-Eubanks Neighborhood Association) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 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. (Rogers-Eubanks Neighborhood Association) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 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. (Rogers-Eubanks Neighborhood Association) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 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 Rogers-Eubanks Neighborhood Association provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Rogers-Eubanks Neighborhood Association) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 County: Finance&Administrative Services Provider: Rogers-Eubanks Neighborhood Orange County Association Post Office Box 8181 101 Edgar Street Hillsborough,NC 27278 Chapel Hill,NC 27516 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 an �� t'b,'Yi p�e at Provider 11/9/2016 5771 E5A400534AF... Date For and obehdifaof Orange County Government 1561A,UA,tt, tka"mt,V'Stt,t1 11/23/2016 0637994&7-SE4A... Bonnie Hammersley, County Manager Date (Rogers-Eubanks Neighborhood Association) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 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. DocuSigneed�by: LJA4President 11/9/2016 Certified by: 00534AF Title: Date: (Provider's Signature) (Rogers-Eubanks Neighborhood Association) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 Exhibit A Provider's Outside Agency Application FOR OFFICE USE ONLY Received By APPLICATION SUBMITTAL CHECKLIST Date/Time / Complete Y/N Agency Rogers Eubanks Neighborhood Association Program(s) Back to School Bash, Garden, Summer Enrichment Camp 1. Cover Page a, m` pplicant Contact Information b. jr-ject/Program Contact Information c. rig unding Requests Identified d. Signed Application Cover Page 2. Agency a. [ ■gency's Years in operation 24 CFR 570.506, Information - b. r Agency's Purpose/Mission 570.507, 570.610, 24 c. 1111 A,ency's Types of Services Provided CFR Parts 84 or 85 d. ICI gency's Experience e. Other Pertinent Information 3. Program/ a. [Type of Application and Program Identified 24 CFR 570.200(a), Project b, E Summary of Program 570.201--570. 208, Information - c. 24/Description of Identified Need 507.503 (for each d, escription of Population to be Served program! e. 1Activity Manager and Location Description project for which funding f. Dr ctivity Implementation Timeline is requested) g. 'Agency Collaboration h. 79escribe Impact of Reduced/No Allocation i. ther Pertinent Information j. omplete Target Population/Beneficiary Chart k. omplete Schedule of Positions I. Conflict of Interest Disclosure m. //igned Complete Work Statement C p 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. rogram Budget Worksheet 570.602, 570.607(b), is requested) b. 2 Program Budget Detail 570.611 c. Cost Per Unit 24 CFR 1 Page DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 [ A - continued Provider's Outside Agency Application MAIN APPLICATION 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; Treasury Circular 1075 5. Supplemental A. E] Part A: CDBGXOME Sections (as B. Ei Part B: Constr c 'on/Rehab applicable) 6. Attachments a. 121tudit: 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 expe, :itures in a fiscal year, must secure an audit. b. E IRS Federal Form 990 c. IIV, Solicitation License d. 1E7/ S Federal Tax-Exemption Letter e. n C"tificate of Insurance f. E./46i of Board of Directors 24 CFR Parts 84 or 85 g. Dr(ic -s of Incorporation/Bylaws 24 CFR 570.208, h. A ithorization to Request Funds TiyA -- 570.500(c), 570.611 I. II A horized official designation j. Solid Waste Program Fee (SWPF) Verification Main Application1/25/2016P a g e 2 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 I 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: Rogers-Eubanks Neighborhood Association (RENA) Applicant Organization's Physical Address: 101 Edgar Street Chapel Hill, N.C. 27516 Applicant Organization's Mailing Address: P.O. Box 16903, Chapel Hill, N.C.27516 Applicant Organization's Web Address: www.rena-center.com Executive Director: Robert L. Campbell Telephone Number: 919-933-6210 E-Mail: rplcampbell©gmail.com DUNS Number: 827097903 (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: Back to School Bash Project/Program Primary Contact and Title: Robert L. Campbell Executive Director Telephone Number: 919-918-2822 E-Mail: rogers.road.cc(gmail.com Project/Program Name: Community Garden Project/Program Primary Contact and Title: Robert L. Campbell Executive Director Telephone Number: 919-918-2822 E-Mail: rogers.road.ccgmail.com Project/Program Name: Summer Enrichment Camp Project/Program Primary Contact and Title: Robert L. Campbell Executive Director Telephone Number: 919-918-2822 E-Mail: rogers.road.cc(c�gmail.com c) Funding Request Identification Total Project/Program Cost: $11,000.00 Total Amount of Funds Requested: $ 16,000 _ Proposed Use of Funds Requested (2-3 Line Maximum): Funds for the Back To School bash will be used on backpacks, school supplies, and event orcastration (clinics, entertainment, and food). Total Project/Program Cost: $ 3,000 Total Amount of Funds Requested: $ 3,000 Proposed Use of Funds Requested (2-3 Line Maximum): Funds for the Community Garden will be used on supplies (garden tools and equpiment, seeds, potting soil) and food and water for voluenteers. Main Application1/25/2016P a g e 3 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Total Project/Program Cost: $ 12,000 Total Amount of Funds Requested: $ 12,000 — Proposed Use of Funds Requested (2-3 Line Maximum): Funds for the Summer Enerichment_ Camp will be used towards field trips, food and day to day camp necessities to include staff_,_, counclers and teachers. 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 n Loan E CDBG Construction (CH) $ ❑ Grant [ Loan r] HOME CHDO (00) $ [ Grant _ Loan C HOME Other (OC) $ ❑ Grant [ Loan n Human Services: // Carrboro $ 20,000 ►1 Chapel Hill $ 20,000 -1 Orange County $ 20,000 d) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. 0A. - \- 4,0 Signature: — 1�' t,or Date Signature: Ex p V 2-� 2.4 Board Chairperson Date Main Application1/25/2016P a g e of 3 2 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 I 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) • Date of Incorporation: The 29th day of Oct. 2007 • Years in Operation: 43 years without incorporation, 8 years incorporated as a nonprofit 501(c)(3) b) Agency's Purpose/Mission • Rogers-Eubanks Neighborhood Association (RENA) seeks to address the environmental, educational and public health issues impacting the residents of our community and to promote a vision of environmental justice and sustainability among residents, partners and other similarly impacted communities. c) Types of Services the Agency Provides • Rogers-Eubanks Neighborhood Association (RENA) provides bags of food which are provided from the food bank at the Rogers Road Community Center. There are Jiu Jitsu classes offered for school aged children as well as adults. After school tutoring which is provided for about 40 kids. Rogers-Eubanks Neighborhood Association also hosts its annual Valentine's Day celebration, Easter Egg Hunt, Fall festival and occasional movie night. The Rogers- Eubanks provides over 400 children with backpacks to start the school year off prepared as well as a Summer Enrichment camp to keep their skills sharp while out of school during the summer. d) Agency's Experience with Similar Programs as the Funding Request • North Carolina Environmental Justice Network- RENA plays an educational role and has won two awards in recent years in recognition of our organizing work • Justice United- Instrumental in giving a snapshot of the diversity of those negatively impacted by the landfill, and helping push back against the waste transfer station. • UNC Chapel Hill, the Bonner Scholars Program, the Campus Y, the Public Health School, Engineers without Borders, UNC Center for Civil Rights and other socially-engaged academic scholars have all helped strengthen our programs as volunteers, researchers, educators, and allies • Marian Cheek Jackson Center for Saving and Making History- helped gather and preserve the stories of neighborhood residents and related data to help us build and present our case before the local governments • Orange County, Carrboro, and Chapel Hill Governments- The Rogers Road small area task force has offered a unified table with neighborhood leaders to work together toward solutions to the unique challenges the Rogers- Eubanks community faces. The municipal governments recognize the need for, and are helping strengthen, the new community center that we hope will be a site of neighborhood-rooted revitalization Main Application1/25/2016P age 5 at 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 A - continued Provider's Outside Agency Application MAIN APPLICATION • Human Resource Center- The children who participate in RENA programs unite with HRC's children to play soccer, play softball, and enjoy movie nights • Habitat for Humanity-H4H residents participate in Community Unity Board, our primary coalitional vehicle, and attend neighborhood celebrations, Back to School Bash, and other functions. • Faith Tabernacle Oasis of Love International Church- Hosts community meetings and other functions as needed. Allowed us to conduct afterschool tutoring, Summer Enrichment Camp, and the Back to School Bash here while we waited for the new community center to be built. Congregation members make small donations to support our work. • Universalist Church on Purefoy- Have offered small donation to support our work, and they are dependable allies when we seek community support for our justice work. e) Other Pertinent Agency Information Main Application1/25/2016P age 6 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 I A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Rogers Eubanks Neighborhood Association Back To School Bash,Commur Garden and Summer Enrichment Camp As you complete your application, complete only those sections that pertain to the type of application you C submitting. The application is divided into several sections and not all sections apply to every project. EVE applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the requir application and required supplemental sections (Parts) as specified below: /1 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) C HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Elderl Disabled Public Housing Program Category Youth Adult Neighborhoods/Resider y (not elderly) Education X X X x __ Health and Nutrition X X X X Job Training X X X X __T Sports and Arts Activities X X X X _ Pre-School Activities X X After-School Activities X Mentoring X X X _ Transportation X X X __ Housing X X X 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/Count priority? • To offer backpacks and supplies to underserved children to improve self-esteem -ft the upcoming school year. • For volunteers, children and community will work together to feed underserve population Main Application1/25/2016P ,age 7 of 3 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 I A - continued Provider's Outside Agency Application MAIN APPLICATION • Offer a six week minimum cost full day program to all participants to assist in closin the educational gap. c) Describe the local need or problem to be addressed in relation to the Consolidated Plan or oth( community priorities (i.e. Council/Board Goals). Cite local data to support the need for this program an the population being served. • The Back To School Bash is designed to serve 500 underserved children to receiv backpacks and school supplies in preparation for the upcoming school year. This designed to bring families and communities together in preparation for the upcomin school year. • RENA will work with community residents to create stewardship. RENA will also us the community and volunteers to work and keep up the maintenance with th Community Garden. And provide produce to the community and to underserve families. • RENA Summer Enrichment Camp is open to 95 1st-10th graders and is a 6 week Ion full day camp with a curriculum based on Orange County and Chapel Hill-Carrboro Cii School learning links modules which will focus on teaching literacy, math, arid scienc skills as well as environmental awareness and stewardship. d) Describe the population to be served or the area to benefit and indicate how you will identify beneficiarie • Back to School Bash will serve Chapel Hill, Orange County, Carrboro residents ar surrounding areas. • Community Garden will serve neighbors within our community as well as? e) Who specifically will carry out the activities and in what location will they be carried out? • Back to School Bash Director (Robert Campbell/Rose Caldwell) • Summer Enrichment Camp (in addition to the above this program will also include 2 ft time assistants and 8 camp counselors) o Executive Director ( ) o President( Minister Robert Campbell) o Operations Manager ( Rosie Caldwell) • Community Garden Master Gardener (Marian Peppers) • Rogers Eubanks Neighborhood Association and volunteers will carry out the, activities and it will be carried out at The Rogers Road Community Center 101 Edg St. Chapel Hill, N.C. 27516 f) Describe specifically the period over which the activities will be carried out, the frequency with which ti activities will be carried out, and the frequency with which services will be delivered. Include implementation timeline. • Back to School Bash is held on the second Saturday in August • Community Garden is an year round project • Summer Enrichment Camp is a 6 week long, Monday — Friday camp. VVith the fir week starting in July. g) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates accomplish or enhance the Projected Results in the Program(s) to be funded. For each, give specil examples of the coordinated/collaborative efforts. • North Carolina Environmental Justice Network- RENA plays an educational role al has won two awards in recent years in recognition of our organizing work • Justice United- Instrumental in giving a snapshot of the diversity of those negative impacted by the landfill, and helping push back against the waste transfer station. • UNC Chapel Hill, the Bonner Scholars Program, the Campus Y, the Public Heal School, Engineers without Borders, UNC Center for Civil Rights and other social engaged academic scholars have all helped strengthen our programs as volunteer researchers, educators, and allies Main Application1/25/2016 ' a g 8o13 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 I A - continued Provider's Outside Agency Application MAIN APPLICATION • Marian Cheek Jackson Center for Saving and Making History- helped gather al preserve the stories of neighborhood residents and related data to help us build a> present our case before the local governments • Orange County, Carrboro, and Chapel Hill Governments- The Rogers Road sm. area task force has offered a unified table with neighborhood leaders to wo together toward solutions to the unique challenges the Rogers-Eubanks communi faces. The municipal governments recognize the need for, and are helpii strengthen, the new community center that we hope will be a site of neighborhoo rooted revitalization • Human Resource Center- The children who participate in RENA programs unite wi HRC's children to play soccer, play softball, and enjoy movie nights • Habitat for Humanity-H4H residents participate in Community Unity Board, o primary coalitional vehicle, and attend neighborhood celebrations, Back to Scho Bash, and other functions. • Faith Tabernacle Oasis of Love International Church- Hosts community meeting and other functions as needed. Allowed us to conduct afterschool tutoring, Summ Enrichment Camp, and the Back to School Bash here while we waited for the n( community center to be built. Congregation members make small donations support our work. • Universalist Church on Purefoy- Have offered small donation to support our woi and they are dependable allies when we seek community support for our justi work. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation recommended. • If no funding is provided we will only be able to provide 100 backpacks with suppliE instead of 500 • If there is no funding for the Community Garden there will be no free fruits an vegetables to help with the afternoon snack for the after school program as well as n fruits or v0egetable to help with the food bags that are passed out from our food bank • If there is no funding for the Summer Enrichment Camp the day to day functions w not be able to be carried out. There will be no science labs, bike rodeos, lunch ( snacks provided for the kids. 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 • Program Director • Executive Director • Operator • Teachers (2 part-time) • Counselors (4 Chapel Hill Youth Program, 4 RENA Youth Program) • Volunteers/Instructors 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 all data collection tools that will be used to verify achievement of program goals and objectives. Descrii who will be responsible for monitoring progress. Main Application 1/25/2016P a g 9 of 3 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION 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: /1 Persons Households ri Units Program: —.—_ — Please indicate whether this project/program will serve: /1 Persons n Households C Units Program: Summer Enrichment Camp Program Beneficiary Demographics Actual Estimate Projt 2014-15 d c 2015-16 201E Gender Male 19 27 30 Female 21 29 30 Total 40 56 Of the females, how many are single-female Head of Households (Omit for Human Services) Ethnicity – – African-American 34 51 50 American Indian or Alaska Native 0 Asian 5 Caucasian 1 5 – Native Hawaiian or other Pacific Islander Other 1 Total 52 Of the above, how many Hispanic/Latino 5 4 0 Of the above, how many non-Hispanic/Latino 35 52 Total 40 56 Age ---- 0-5 years 6-18 years 40 56 _ 60 19-50 years 51-61 years 62+ years Total 40 56 Main Application1/25/2016P age 10 of DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Geographic Location Durham City Durham County 4 Carrboro 4 8 Chapel Hill 33 35 17 Chapel Hill Public Housing Residents Orange County _ 3 17 35 Raleigh Wake County _ Total 40 56 Main Application 1/25/2016P a g e 11 of 3 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Please indicate whether this project/program will serve: I 1 Persons [1 Households n Units Program: Back to School Bash Program Beneficiary Demographics Actual Estimate Prole( 2014- d d 15 2015-16 2016- Gender Male 158 200 Female 183 200 Total 0 341 4 Of the females, how many are single-female Head of Households (Omit for Human Services) Ethnicity --African-American _ 190 200 American Indian or Alaska Native 0 0 Asian 134 150 Caucasian 2 20 Native Hawaiian or other Pacific Islander _ Other 15 30 Total 0 0 4 Of the above, how many Hispanic/Latino 15 25 Of the above, how many non-Hispanic/Latino 326 Total 0 15 Age 0-5 years 121 150 6-18 years 200 225 19-50 years 20 ! 25 51-61 years 62+years Total 0 0 Geographic Location — Durham City Durham County Carrboro 37 _ 50 Chapel Hill 226 250 Chapel Hill Public Housing Residents Orange County — 78 100 Raleigh Wake County Total 0 341 4 Main Application1/25/2016P a g e 12 of 3 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION 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 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total 0 0 Main Application1/25/20161` a g a 13 of 3 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION CDBG & HOME ONLY - Area Benefit Activities (Infrastructure and Public Facilities) Street Census Tract Block Group Total Persons #LMI Persons 2015 Area Median Family income Limits - U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Income 1 2 3 4 5 6 7 8 Level person people people people people people people people 30% AMI $14,15 $16,20 $20,09 $24,25 $28,41 $32,57 $36,73 $40,890 0 0 0 0 0 0 0 50% AMI $23,60 $27,00 $30,35 $33,70 $36,40 $39,10 $41,80 $44,500 0 0 0 0 0 0 0 80% AMI $37,75 $43,15 $48,55 $53,90 $58,25 $62,55 $66,85 $71,150 0 0 0 0 0 0 0 100% AMI $47,18 $53,93 $60,68 $67,37 $72,81 $78,18 $83,56 $88,937 8 8 8 5 3 8 3 115% AMI $54,26 $62,02 $69,79 $77,48 $83,73 $89,91 $96,09 $102,27 6 8 1 1 4 6 7 8 http://www.huduser.org/portal/datasets/il/i115/FY2015 IL nc.pdf Main Application1125/2016P a g e 1 A of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION k.) Schedule of Positions Please include program staff positions followed by volunteer positions; these financial figures should match the personnel figures in your Agency Comparative Budget Excel Form. Similar positions can be combined. (i.e., 8 Occupational Therapists can be inserted as one line item). If provided, indicate: Position Titles % Projecte %/o (R) FTE *= Position * Program Actual Estimated d 2016- Total Retirement Vacant Staff+ 2014-15 2015-16 17 Budget Plan (H) Health Plan Back to school bash Executive Director 1.0 40 Hours -0- 400 hours 400 hours President 1.0 40 hours -0- 400 hours 400 hours _ Operations manager 1.0 40 hours -0- 400 hours 400 hours Volunteers 6.0 36 hours Community 8 hrs a Garden/Master month for 2 hrs a 2 hrs a 2 hrs a Gardner 1.0 7 months week week week 8 hrs a month for 20hrsx5 40hrsx 50hrsx5 Volunteers 1.0 7 months = 100 hrs 5=200 hrs =250 hrs Summer Camp/3 40 hrs x 3 5x 120 = Administrators 1.0 =120 hrs 600 hrs 600 hrs 720 hrs 2x40 x 5 2x40 x 6 weeks= weeks Teachers 1.0 400 hrs =480 hrs 600 hrs 720 hrs 4 x 16 x5=320 4 x 16 x 5 Counselors 1.0 hrs = 320 320 hrs 400 his 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 Application1/25/2016 ' age 15 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 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 ❑ 0 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? 0 ® 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. Signature: • 1% d\ Executive Director a Date Signature: / / ? Board Chairperson Date Main Application 2/2/2016 9:35:46 AM Page 1 7 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Prograrr Back to School Bash ri-V041V: AGENCY REVENUE 0,2014415 201647 Private Donations $ 3,000 $ 5,000 $ 7,000 40% Agency Generated Revenue(fees) 0 Local Government Grants Orange County $ 10,000 $ 15,000 $ 8,000 -47% Town of Chapel Hill $ 2,000 $ 2,500 $ 3,000 20% Town of Carrboro $ 2,500 $ 3,000 $ 3,500 17% Other Local: 0 Other Local: 0 Other Local: 0 If more than 3 sources,please provide a separate 1st. Non-Local Government Grants Triangle United Way 0 State Govemment 0 Federal Gmemment 0 Other Grants:2 Smith Reynolds - $ 10,000 $ 10,000 0% Other Grants: 0 Miscellaneous/Other Revenue 0 Please list 3 largest Iviscellanous sources: - $ - Total Agency Revenue $ 17 500 $ 35 500 $ 31 500 -11% AGENCY EXPENSES Compensation 0 Rent&Utilities 0 Supplies&Equipment 0 Travel&Training 0 Other Expenses: 0 Please list 3 largest"Other Expenses": - Total Agency Expenses - $ - $ 0 SURPLUS/(DEFICIT)FOR PERIOD: 1$ 17,500 I$ 35,5001$ 31,500 I -11% Main Application 2/2/2016 5:08:53 PM Page 23 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program: Garden C UaK 1". tt:0*d„ a t*Ote4k.F i r->e. er AGENCY REVENUE ,k201 � l „2l)d5-16 .20.1617, ' Private Donations $ 200 $ 500 $ 1,000 100% Agency Generated Revenue(fees) 111111111 0 Local Government Grants: Orange County $ 1,000 $ 1 500 $ 1,100 Town of Chapel Hill $ 1 000 $ 1,500 $ 2,000 33% Town of Carrboro $ 500 $ 500 $ 1 000 100% Other Local: -- 0 Other Local: r 0 Other Local: - 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way -111111111111111- 0 State Government -- 0 Federal Government -11111111111111 r 0 Other Grants:Z Smith Reynolds MN= $ 1 000 $ 5,000 400% Other Grants:Strowd Rose $ 2,000 $ 2,000 0% Miscellaneous/Other Revenue _ 0 Please list 3 largest MiscellanOus sources: $ - $ - Total Agency Revenue 2 700 7 000 12100 73% AGENCY EXPENSES Compensation 0 Rent&Utilities 0 Supplies&Equipment �-_ 0 Travel&Training 111111_ 0 Other Expenses: 111111111 0 Please list 3 largest"Other Expenses": $ - $ Total Agency Expenses 0 SURPLUS/(DEFICIT)FOR PERIOD: I$ 2,700 I$ 7,000 1$ 12,100 I 73%I Main Application 2/2/2016 5:09:31 PM Page 27 of 32 • • DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Program: Summer Enrichment Camp ,4 $,Alitua! Fstlmate Projected,> 5#,P, tt AGENCY REVENUE 0144-5. y'' .,'2i115`i6,;'; ,2Q16 4T K C,h�itt e Private Donations $ 1,000 $ 3,000 $ 5 000 67% Agency Generated Revenue(fees) 0 Local Government Grants: Orange County $ 1,500 $ 7,000 $ 10,900 56% Town of Chapel Hill $ 1 500 $ 2,000 $ 1,000 -50% Town of Carrboro $ 1,000 $ 2,500 $ 3 000 20% 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 --- 0 State Government 0 Federal Government 0 Other Grants:Z Smith Reynolds $ - $ 10 000 $ 10 000 0% Other Grants:Strowd Rose $ 5,000 $ 5,000 0% Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: BNY Mellon $ 5,000.00 $ $ - Total Agency Revenue 5 000 29 500 34 900 '11 AGENCY EXPENSES Compensation 0 Rent&Utilities -__ 0 Supplies&Equipment --_ 0 Travel&Training 01111 0 Other Expenses: --_ 0 Please list 3 largest"Other Expenses": $ - $ Total Agency Expenses 0 SURPLUS/(DEFICIT)FOR PERIOD: '$ 5,000 I$ 29,500 I$ 34,900 I 18%l Main Application 2/2/2016 5:08:53 PM Page 24 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION m.) Work Statement This form is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. ® Program Activities should outline major activities the agency implements to accomplish its '... program goals. ® Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. SMART Goals ® Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. Main Application1/25/2016P a g e °i 8 o f 3 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Actual Estimated Projected 2014-2015 2015-2016 2016-2017 Program Activity 1 Back to School Bash Back to School Bash Back to School Bash To provide 500 back To provide 500 back To provide 500 back packs fill with school packs fill with school packs filled with school supplies to 500 low supplies to 500 low supplies to 500low Prram Goal income students income students income students Designed to bring Designed to bring Bring families and families and families and communities together in communities together in communities together in prepartion for the preparation for the preparatin for the Performance Measures u•comin: school ear u•comin_ school ear upcoming school year Approximately 500 back Approximately 550 back 500 back packs will be Program Results packs distributed packs distributed distributed Program Activity 2 Garden Garden Garden To provide fresh To provide fresh To provide fresh vegetables to feed vegetables for vegetables for Program Goal undeserved popoulation underserved population underserved population Prepare the garden, Prepare the garden, Prepare the garden, planting weeding, planting, weeding, planting, weeding, harvesting, and harvesting, and harvesting, and Performance Measures distributing produce distributing produce distributinaoduce Approximately 30 Approximately 60 Approximately 90 household will benefit household will benefit household will benefit receiving fresh produce receiving fresh produce receiving fresh produce throughout the growing throughout the growing throughout the growing Program Results season season season Summer Enrichment Summer Enrichment Summer Enrichment Program Activity 3 Camp Camp Camp Offer a six week free day Offer a six week free day Offer a six week free day program to all progam to all program to all participants to assist in participants to assist in participants to assist in closing the education closing the education closing the education Program Goal gap Lap gap Academic enrichment, Academic enrichment, Academic enrichment, literacy, math, and literacy, math, and literacy, math, and science skills(will offer science skills (will offer science skills(will offer broad exposure to broad exposure to broad exposure to enviornment awareness, enviornment awareness, enviornment awareness, enviornment enviornment enviornment stewardship, community stewardship, community stewardship, community Performance Measures history iA ,- f. hii5toryil Mairr �`l �tion1/2 /201 Go � � e; � Participation and a Participation and a Participation and a graduation ceremony, graduation ceremony, graduation ceremony, DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application112512016P a g a 21 at 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Progran Back to School Bash Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Chan•e Private Donations $ 3,000 $ 5,000 $ 7,000 40% Agency Generated Revenue (fees) 0 Local Government Grants: Orange County $ 10,000 $ 15,000 $ 20,000 33% Town of Chapel Hill $ 2,000 $ 2,500 $ 3,000 20% Town of Carrboro $ 2,500 $ 3,000 $ 3,500 17% 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 0 State Govemment 0 Federal Government --- 0 Other Grants:Z Smith Reynolds $ - $ 10,000 $ 10,000 0% Other Grants: --- 0 Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: $ - $ - $ - Total Agency Revenue 17 500 35 500 43 500 23% AGENCY EXPENSES Compensation �-� 0 Rent&Utilities 0 Supplies&Equipment 0 Travel &Training 0 Other Expenses: 0 Please list 3 largest"Other Expenses": $ - $ - $ - Total Agency Expenses 11111.111111111.11111 0 SURPLUS/(DEFICIT)FOR PERIOD: L$ 17,500 I $ 35,500 I $ 43,500 I 23% Main Application1/25/20161 a g e 22 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Prograrr Summer Enrichment Camp Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Chan•e Private Donations $ 1,000 $ 3,000 $ 5,000 67% Agency Generated Revenue (fees) -- 0 Local Government Grants: Orange County $ 1,500 $ 7,000 $ 10,000 43% Town of Chapel Hill $ 1,500 $ 2,000 $ 1,000 -50% Town of Carrboro $ 1,000 $ 2,500 $ 3,000 20% 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 --- 0 State Government --_ 0 Federal Government Other Grants:Z Smith Reynolds $ - $ 10,000 $ 10,000 0% Other Grants:Strowd Rose $ 5,000 $ 5,000 0% Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: BNY Mellon $ 5,000.00 $ - $ - Total Agency Revenue 5 000 29 500 34 000 15% AGENCY EXPENSES Compensation 0 Rent&Utilities Supplies&Equipment _-_ 0 Travel&Training __- 0 Other Expenses: --- 0 Please list 3 largest"Other Expenses": $ - $ - $ - Total Agency Expenses 0 SURPLUS/(DEFICIT)FOR PERIOD: I $ 5,000 I $ 29,500 I $ 34,000 I 15% Main Application1/25/2016P a g e 23 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Prograrr Garden Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Chan.e Private Donations $ 200 $ 500 $ 1,000 100% Agency Generated Revenue (fees) --- 0 Local Government Grants: Orange County $ 1,000 $ 1,500 $ 2,000 33% Town of Chapel Hill $ 1,000 $ 1,500 $ 2,000 33% Town of Carrboro $ 500 $ 500 $ 1,000 100% 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 --- 0 State Government --- 0 Federal Govemment --- 0 Other Grants:Z Smith Reynolds $ - $ 1,000 $ 5,000 400% Other Grants:Strowd Rose - $ 2,000 $ 2,000 0% Miscellaneous/Other Revenue Please list 3 largest Miscellanous sources: $ - $ - Total Agency Revenue 2 700 7 000 13 000 AGENCY EXPENSES Compensation --- 0 Rent&Utilities _-_ 0 Supplies&Equipment -_ 0 Travel&Training 0 Other Expenses: _-_ 0 Please list 3 largest"Other Expenses": $ - $ Total Agency Expenses M1111.111111.11111 0 SURPLUS/(DEFICIT)FOR PERIOD: $ 2,700 I $ 7,000 I $ 13,000 I 86% Main Application1/25/2016P age 26 0 f 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION b) Program Budget Detail What is the cost to deliver your project/program? List each project/program element in the table below, including the cost of each element, the quantity and unit of measure, and the subtotal for each element. Where necessary, allocate costs to the use of shared space, vehicles or equipment. Example Program: Credit Counseling Class Cost Elements Cost($) Quantity/Unit of Measure Subtotal ($) Credit Counseling Teacher–in class $25 96 hours (8 hrs/mth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 48 hours (4hrs/mth x 12 mths) $1,200 Credit Counselor—one-on-one $20 120 hours (10 hrs/mth x12 mths $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 Complete the table below for the project/program for which you are requesting funds. Attach additional rows/pages, as needed. Program: Back to School Bash Cost Elements Cost($) Quantity/Unit of measure Subtotal (! - Back Packs $5.00 1=$5.00 (5x 400) $2,000 _ Supplies $5.00 1=set(5x400) $2,000 _ Food $8.00 1 meal= $8.00 (800x$8.00) $6,400 Orchestration $400.00 1=$400.00 (3x400) $1200 Total $11,600 b) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $11,000 $11,600 $12,000 Total # of Units $400.00 $400.00 $400.00 Cost Per Unit $10.00 $10.00 $10.00 Program: Garden Cost Elements Cost($) Quantity/Unit of measure Subtotal($) Supplies(seeds, tools and soil) $1000 $1000 Storage building w/accessories $500.00 Storage building w/accessories $500.00 Main Application1/25/2016P age 27 of S2 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Food (water, Gatorade, snacks 6 months) $600.00 $600.00 Gas and oil $100.00 2.50 per gallon(40 gallons) $100,00 Total $2200.00 b) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $2,000 $2200.00 _$3000.00 Total # of Units _ 1= 1/4 acres 1=1/4 acres 1=1/2 acres Cost Per Unit $2000.00 $2200.00 $3000.00 Program: Summer Enrichment Camp Cost Elements Cost($) Quantity/Unit of measure Subtotal (SI Classes (instructors) $200.00 200x4 classes $800.00 Food $5.00 5x60 students x25 days $1500.00 Field trips $300.00 2 field trips x300 $600.00 Teachers $1000.00 2 teachers x1000 $2000.00 Counselors (RENA) _ $500.00 500x 4 counselors x 5 weeks $2000.00 Administrators $2000.00 3 x 2000 $6,000.00 Total $12,900.00 b) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program $11,000.00 18,000.00 $20,000.00 Total # of Units 40 60 60 Cost Per Unit $275.00 per $315.00 per student student $333.00 per student 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 Application1/25/20161° a g e 28 o f 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t 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. 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 Application1/25/2016P a g e 29 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 t A - continued Provider's Outside Agency Application MAIN APPLICATION Section VI.Financial Data Operating Budget for Entire Agency AGENCY NAME: Rogers Eubanks Neighborhood Association Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Chan•e Private Donations $ 8,000 $ 11,000 $ 15,000 36% Agency Generated Revenue(fees) $ 5,000 $ 8,000 $ 12,000 50% Local Government Grants: Orange County $ 5,000 $ 20,000 $ 25,000 25% Town of Chapel Hill .0. $ 5,000 $ 20,000 300% Town of Carrboro $ 6,000 $ 6,000 $ 10,000 67% Other Local: --1 0 0 Other Local: -- Other Local: --- 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way --� 0 State Government - 0 Federal Government 0 Other Grants:Z Smith Reynolds .0. $ 15,000 $ 15,000 0% Other Grants:Strowd Rose .0. $ 5,000 $ 5,000 0% Miscellaneous/Other Revenue 0 Please list 3 largest Miscellanous sources: $ - $ - $ - Total Agency Revenue • 24 000 • 70 000 • 102 000 46% AGENCY EXPENSES Compensation --� 0 Rent&Utilities _. 0 Supplies&Equipment 0 Travel&Training 0 Other Expenses: Please list 3 largest"Other Expenses": Insurance $ 3,069.16 $ - Total Agency Expenses m.__._. 0 SURPLUS/(DEFICIT)FOR PERIOD: I$ 24,000 I$ 70,000 I $ 102,000 46°/ Main Application1/25/2016P a g a 30 of 32 DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Rogers-Eubanks Neighborhood Association Funding Award: $20,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Summer Enrichment Camp—Back to School Bash—Community Garden 20,000 Programmatic Expenses 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. • The back to School Bash: is to send neighborhood youth back to school with the message that their community believes that education is important, and help provide material assistance to underscore this commitment to education. The program aims to provide parents and students withsupplies necessaryfor scholastic success. • Community Garden is providing opportunity for connection and introduction that helps develop the Centers outreach. In addition to providng healthy food it offers a forum for relationship building. • Summer Enrichment Camp: is open to about 60 preschool through 11`'' grade. The six week, full day camp curriculm based on County and Chapel Hill City Schools learning links modules will focus on teaching literacy, math, and science skills, as well as environmental awareness ans stewardship. 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 Backpacks distributed to low income students 500 back packs Households will benefit receiving fresh produce throughout the growing season 90 households Offer a free day program to all participants to assist in closing the education gap 6 weeks e. —DocuSigned by: Program Manager 11/21/2016 DocuSigneed�by y:, 0a President Certified by: 5771E5A400534AF... Title: Date: 11/9/2016 (Provider's Signature) DocuSign Envelope ID: EB541A3B-1E01-49AB-9E09-7987ECAEC1C4 ACC?R°J CERTIFICATE OF LIABILITY INSURANCE 09/14/2016 L.,.r THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Jean Droese SEAGROVES AGENCY, INC PHONE FAX 1506 E E. FRANKLIN STREET (A/C,No,Ext): 919-542-3750 (A/C,No): 919-967-0411 Mass:SUITE 100 ADDRESS: j@nationwide.com CHAPEL HILL NC 27514 INSURER(S)AFFORDINGCOVERAGE NAIC# INSURERA: NAUTILUS INSURANCE COMPANY 17370 INSURED INSURER B: ROGERS-EUBANKS NEIGHBORHOOD ASSOCIATION PO BOX 16903 INSURERC: CHAPEL HILL NC 27516 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL INSR SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY X NN726382 09/15/2016 09/15/2017 EACH OCCURRENCE $1 , 000 , 000 A X COMMERCIAL GENERAL LIABILITY PR S RENTED PREMISES((Ea occurrence) $100 , 000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $5, 000 PERSONAL&ADV INJURY $1 , 000 , 000 GENERAL AGGREGATE $2, 000 , 000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $INCLUDED X POLICY PRO- JECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) OUTREACH CENTER. CERTIFICATE HOLDER IS LISTED AS ADDITIONAL INSURED PER FORM CG2010 7/04) . CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ORANGE COUNTY GOVERNMENT AUTHORIZED REPRESENTATIVE PO BOX 8181 HILLSBOROUGH NC 27278 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD