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2016-672-E Finance - Triangle Bikeworks - Outside Agency Performance Agreement
DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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 Triangle Bikeworks, a not-for-profit corporation, located at P.O. Box 17202, Chapel Hill,NC 27514 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Triangle Bikeworks 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$1000. 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 $ 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. (Triangle Bikeworks) Orange County Outside Agency Performance Agreement Revised 8/2016 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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. (Triangle Bikeworks) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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. (Triangle Bikeworks) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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 Triangle Bikeworks 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: (Triangle Bikeworks) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 County: Finance&Administrative Services Provider: Triangle Bikeworks Orange County 115 West Main 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.r For a uh leaiIf of the Provider ko.4 9LrJuD, 11/22/2016 €AV-3c942aac... Date co combo/half of Orange County Government lA tka"mt-I'Stt 1 11/28/2016 8637991 B755E177... Bonnie Hammersley, County Manager Date (Triangle Bikeworks) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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: Certified b LRR6FAF! ,4RC Title: Executive Di rector Date: 11/22/2016 Y (Provider's Signature) (Triangle Bikeworks) Orange County Outside Agency Performance Agreement Rev. 8/16 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 Exhibit A Provider's Outside Agency Application APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency Triangle Bikeworks Date/Time / 1 Complete Y/N Program(s) Spoke'n Revolutions Youth Cycling Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. ® Applicant Contact Information b. ® Project/Program Contact Information c. ® Funding Requests Identified d. ® Signed Application Cover Page 2. Agency a. ® Agency's Years in operation 24 CFR 570.506, Information - b. ® Agency's Purpose/Mission 570.507, 570.610; 24 c. ® Agency's Types of Services Provided CFR Parts 84 or 85 d. ® Agency's Experience e. ® Other Pertinent Information 3. Program/ a. ® Type of Application and Program Identified 24 CFR 570.200(a), Project b. 570.201-570. 208, ® Summary of Program Information - c. ® Description of Identified Need 507.503 (for each d. ® Description of Population to be Served program/ project for e. ® Activity Manager and Location Description which funding f. ® Activity Implementation Timeline is requested) g. ® Agency Collaboration h. ® Describe Impact of Reduced/No Allocation i. ® Other Pertinent Information j. ® Complete Target Population/Beneficiary Chart k. ® Complete Schedule of Positions I. ® Signed Conflict of Interest Disclosure m. ® Complete Work Statement i o:° DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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. ❑ Part A: CDBG & HOME Sections (as B. ❑ Part B: Construction/Rehab applicable) 6. Attachments a. [' Audit: Organizations receiving $300,000 or more OMB Circular A-133 in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ® NC Solicitation License d. ® IRS Federal Tax-Exemption Letter e. ❑ Certificate of Insurance f. ® List of Board of Directors 24 CFR Parts 84 or 85 g. ® Articles of Incorporation/Bylaws 24 CFR 570.208, h. ® Authorization to Request Funds 570.500(c), 570.611 i. ® Authorized official designation j. ® Solid Waste Program Fee (SWPF) Verification Main Application 5/25/2016 10:17:47 AM P 2 of 2 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t 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: Triangle Bikeworks Applicant Organization's Physical Address: 115 W. Main Carrboro, NC 27510 Applicant Organization's Mailing Address: P.O. Box 17202 Chapel Hill, NC 27514 Applicant Organization's Web Address: http://trianglebikeworks.org Executive Director: Kevin Hicks Telephone Number: 919-949-3359 E-Mail: kevinatrianglebikes.org DUNS Number: (Dun & Bradstreet, Inc. provides this number at no charge, and it is required for Federal funding recipients.) b) Proiect/Proqram Contact Information Project/Program Name: Spoke'n Revolutions Youth Cycling Project/Program Primary Contact and Title: Kevin Hicks Telephone Number: 919-949-3359 E-Mail: kevin( trianglebikes.orq c) Funding Request Identification Total Project/Program Cost: $15,000Total Amount of Funds Requested: $7,500 Proposed Use of Funds Requested (2-3 Line Maximum): 2017 summer tour cycling sections of the Trail of Tears 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) $ 0 Grant 0 Loan LI CDBG Construction (CH) 0 Grant 0 Loan 10 HOME CHDO (OC) El Grant LI Loan 0 HOME Other(OC) 0 Grant 0 Loan LI Human Services: 4, Carrboro $3250 I Chapel Hill $3250 Orange County $1000 d) To the best of my knowledge and belief all information and data in this application is true an• rrent. The document has been duly authorized by the governing board of the appli,ant. Signature: ,-9/ th/ Air Aw- D- Signature: pOlo. Z q ard Chairperson Date Main Application 1/24/2016 2:55:18 PM Page 3 of 20 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application Chapel Hill,NC 27514 TRIANGLE BIKE WORKS BREVIC T 919-949-3359 EicLeatriaaebtkeworks org. www trianglebikeworks org January 24,2016 Jackie Thompson Nate Broman-Fulks Allen Coleman Dear members of the Human Services Grant Committee, This serves as authorization for Kevin Hicks to negotiate for and contractually bind Triangle Bikeworks. Authorized addresses: Executive Director Kevin Hicks 919-949-3359 920 Shady Lawn Road Ext Chapel Hill,NC 27514 Vice Chair Anthony Pergolotti 919-475-2455 508 Oak Avenue Carrboro, NC 27510 This is also to state that Triangle Bikeworks is exempt from Solid Waste Program Fee because it does not own property as outlined in the ordinance. Sincerely yours, Anthony Pergolotti Vice Chair , -- — Triangle Bikework DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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 I=1 I a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? E] c) Current beneficiaries of the project/program for which funds are requested? d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclose• • lict may result in the termination of any grant awarded. tm._ Signature: E re I irecto Date , / Signature: /7 - :oard Chairperson Date Main Application 1/24/2016 2:56:25 PM Page 11 of 20 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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 Years in Operation and Agency's Purpose Triangle Bikeworks has been in operation for four years and incorporated in the state of North Carolina since October 2012. The purpose of Triangle Bikeworks is to create opportunities for young people to learn and practice lessons in leadership, health and wellness, self-esteem, achievement and environmental stewardship through bicycle education programs and volunteer service trips. Types of Services the Agency Provides Triangle Bikeworks provides a non-traditional means of physical activity and education. Through the Spoke'n Revolutions Youth Cycling program youth are engaged in a physically demanding, albeit less aerobic, means of travel. Using the bicycle, youth travel pre-designated routes where they are able to learn the culture and history of the region they bike through. By exposing young people to new challenges, other cultures and diverse environments through a challenging hands-on experience, Triangle Bikeworks believes we can open young people's eyes to new ways of thinking and inspire them to create positive change in their own lives and communities for the future. After the first tour in 2011 of the Underground Railroad it was written that the program "is project- based learning at its best, combining travel to powerful places with authentic experience of history and geography, collaboration towards a common goal, and intense physical activity." Of a more competitive nature,Triangle Bikeworks offers Cyclocross racing, a form of in-park bike races where the youth can measure themselves against others to have a goal for improvement. Cyclocross is an intensive 30 minute race that happens each fall season. Mountain Bike racing is another competitive offering that makes use of the wonderful trail system in our region and state. Similar in intensity to cyclocross, mountain bike racing will challenge youth to set achievable goals and work together as a team. A growing body of research literature finds that in addition to improved physical health, sport plays a primarily positive role in youth development, including improved academic achievement, higher self-esteem, fewer behavioral problems, and better psychosocial. Many studies focus on the effects of sport on the five "C's"—Competence, Confidence, Connections, Character, and Caring—which are considered critical components of positive youth development.2 1 http://www.edutopia.org/blog/project-based-learning-national-parks-milton-chen 2 http://truesport.org/resources/publications/reports/psychological-and-social-benefits-of-playing-true-sport/ Main Application 5/25/2016 10:17:47 AM .. of 2 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application MAIN APPLICATION Agency's Experience with Similar Programs as the Funding Request Triangle Bikeworks has no experience with other agencies with similar youth touring or project based learning programming. In 2013, Triangle Bikeworks was successful in creating the seed program for the Youth Hammercross Cyclocross program put on by the adults in the men's Hammercross cyclocross team. Other Pertinent Information Triangle Bikeworks will also be instrumental in the formation of a team of youth participating in the North Carolina Interscholastic Cycling Association's (NCICA) mountain bike racing league. Youth mountain bike racing will begin training and team formation fall of 2016 with races starting spring 2017. Main Application 5/25/2016 10:17:47 AM .. g 5 of 20 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency & Program Name: Triangle Bikeworks - Spoke'n Revolutions Youth Cycling As you complete your application, complete only those sections that pertain to the type of application you are submitting. The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: ❑ Human Services (Main Application Only) ❑ CDBG Non-Construction — (Main Application AND Part A) ❑ CDBG Construction — (Main Application AND Part A AND Part B) ❑ HOME CHDO Set-aside — (Main Application AND Part A) ❑ HOME Other — (Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Program Category Youth Adult Elderly Disabled Public Housing (not elderly) Neighborhoods/Residents Education X Health and Nutrition Job Training Sports and Arts Activities X Pre-School Activities After-School Activities X Mentoring X Transportation X Housing 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 5/25/2016 10:17:47 AM P 6 of 20 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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 Complete j.) Target Population Complete the following tables to the best of your ability. Show numbers of participants and percentages, as applicable, in each category. Please indicate whether this project/program will serve: ® Persons ❑ Households ❑ Units Program: Program Beneficiary Demographics Actual Estimated Projected 2014-15 2015-16 2016-17 Gender Male 7 13 13 Female 6 10 10 Total 13 23 23 Of the females, how many are single- female Head of Households (Omit for Human Services) Ethnicity African-American 4 11 11 American Indian or Alaska Native Asian 6 4 4 Caucasian Native Hawaiian or other Pacific Islander Other(Latino) 3 8 8 Total 13 23 23 Main Application 5/25/2016 10:17:47 AM P of 20 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application MAIN APPLICATION Of the above, how many Hispanic/Latino 3 8 8 Of the above, how many non- Hispanic/Latino 10 15 15 Total 13 23 23 Age 0-5 years 6-18 years 13 23 23 19-50 years 51-61 years 62+ years Total 13 23 23 Geographic Location Durham City Durham County Carrboro Chapel Hill 13 23 23 Chapel Hill Public Housing Residents Orange County Raleigh Wake County Total 0 0 0 Income Level —See following chart (Omit for HS) < 30%Area Median Income 31-50% Area Median Income 11 22 22 51-80% Area Median Income > 80%Area Median Income 2 1 1 Total 12 23 23 Special Needs (Omit for HS) Elderly(Over 62) Disabled (not elderly) Homeless People with HIV/Aids Total 0 0 0 Main Application 5/25/2016 10:17:47 AM .. of 2 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application MAIN APPLICATION CDBG & HOME ONLY- Area Benefit Activities (Infrastructure and Public Facilities) Street Census Tract Block Group Total Persons #LMI Persons 2015 Area Median Family income Limits U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Income 1 2 3 4 5 6 7 8 Level person people people people people people people people 30% AMI $14,150 $16,200 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 50% AMI $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500 80% AMI $37,750 $43,150 $48,550 $53,900 $58,250 $62,550 $66,850 $71,150 100% AMI $47,188 $53,938 $60,688 $67,375 $72,813 $78,188 $83,563 $88,937 115% AMI $54,266 $62,028 $69,791 $77,481 $83,734 $89,916 $96,097 $102,278 http://www.huduser.ord/portal/datasets/il/ill 5/FY2015 IL nc.pdf Main Application 5/25/2016 10:17:47 AM F 0 of 20 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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 % (R) *= Position FTE* Program Actual Estimated Projected %Total Retirement Vacant Staff+ 2014-15 2015-16 2016-17 Budget Plan (H) Health Plan Volunteer Exec Dir 1 1 1 0 Notes: • Similar positions can be combined: i.e. 8 Occupational Therapists can be inserted as one line item. • ** Full Time Equivalent staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • + Denotes the percentage of staff time involved with this program. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 1,960 Main Application 5/25/2016 10:17:47 AM P 10 of 2 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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. Actual Estimated Projected 2014-2015 2015-2016 2016-2017 I I I I I I I I I I I I I I I I I I I I I I I1 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I1 I I I I I I I I I1 I I I I I I I I I I I I I I I I I1 I I I I I I I I I I I I I I I I I I I I I I I 111 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 111 I I I I I I I I I I I I I I I 111 I I I I I I h I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I1 I I I I I I I I I I I I I I I I I1 I I I I I I I1 I I I I I I I I I I I I I I I I I1 I I I I I I I I I1 I I I I I I I I I I I I I I I I I1 I I I I I I I1 I I I I I I I I I I I I I I I I I1 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I Program Activity 1 Program Goal Performance Measures Program Results Program Activity 2 Program Goal Performance Measures. Program Results M111111111111111111111111111111.101 Program Activity 3 Program Goal Performance Measures Program Results 3313131313131313131313111111313111111113333333311111331HEINEMEMMENNEMIMEINIMMEMMIEIMI Program Activity 4 Program Goal Performance Measures Program Results 1111111111I .111 , Program Activity 5 Program Goal Performance Measures Program Results Main Application 5/25/2016 10:17:47 AM Pa 12 of 2 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application MAIN APPLICATION 4. FINANCIAL INFORMATION FOR SERVICE PROGRAMS a.) Program Budget Please complete a Program Budget Excel Form for each requested program. The Program Budget should reflect only figures and amounts associated with the Program(s) for which you are seeking funding and not the total agency budget. If the program's finances experienced significant changes that you would like to explain, please use the space below. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/25/2016 10:17:47 AM Pag 13 of 2 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program Budget Agency/Progran Spoken Revolutions Youth Cycling Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 12,101 $ 15,000 $ 16,500 10% Agency Generated Revenue (fees) $ - $ - $ - 0 Local Government Grants: Orange County $ - $ 1,250 $ 1,000 -20% Town of Chapel Hill $ - $ 1,250 $ 1,250 0% Town of Carrboro $ - $ 1,250 $ 1,250 0% Other Local: $ - 0 Other Local: $ - 0 Other Local: $ - 0 It 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: $ - 0 Other Grants: $ - 0 Miscellaneous/Other Revenue $ 2,000 $ - $ - 0 Please list 3 largest Miscellanous sources: Bressler Foundation $ 2,000.00 Total Agency Revenue $ 14 101 $ 18 750 $ 20 000 7% AGENCY EXPENSES Compensation $ - $ - $ - 0 Rent&Utilities $ - $ 1,000 $ 1,100 10% Supplies&Equipment $ - $ 333 $ 333 0% Travel &Training $ - $ 250 $ 250 0% Other Expenses: $ 13,940 $ 15,000 8% Please list 3 largest"Other Expenses": $ 13 828 Doke'n Revolutions Summer To $ 10,265.00 Contract Services $ 1,875.00 Insurance and Other Expenses $ 1,688.00 Total Agency Expenses $ 13,828 $ 15,523 $ 16,683 7% SURPLUS/(DEFICIT)FOR PERIOD: $ 273 $ 3,227 $ 3,317 3°/ Main Application 5/25/2016 10:17:47 AM .. i 1 4 o of 2 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 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: S•oke'n Revolutions' Trail of Tears Tour 2017 Cost Elements Cost( ) Quantity/Unit of measure Subtotal( ) Program Participants and Chaperones 222.75 13 2895.75 Camping Accommodations 86.85 15 1302.75 Food 166.04 15 2490.71 Support Vehicle Fuel 1990.19 1 1990.19 Contract Services 1875.00 1 1875.00 Tour Jerseys 76 15 1140.00 Insurance 1688.00 1 1688.00 Total 13,382.40 C.) Cost per Unit Actual 2014-15 Estimated 2015-16 Projected 2016-17 Total Cost of Program 13,828.00 13,382.40 15,000.00 Total # of Units 15 15 15 Cost Per Unit 921.86 892.16 1000.00 This Cost Per Unit must reflect the total program budget and the total number of program beneficiaries (households or persons) in this application and must be consistent with report submittals from previous years (if applicable). Main Application 5/25/2016 10:17:47 AM P 15 of 20 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application MAIN APPLICATION d.) Agency Operating Budget Please show all sources and amounts of funding for your entire current fiscal year. What is your agency's fiscal year? Example: July 1, 2016 through June 30, 2017. It is required that your Excel budget worksheet be embedded on the next page. You must also submit an electronic copy of the MS Excel file with your application, as a separate file. Main Application 5/25/2016 10:17:47 AM .. g 16 of 20 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application MAIN APPLICATION Section VI.Financial Data Operating Budget for Entire Agency AGENCY NAME: Triangle Bikeworks Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 31,798 $ 20,000 $ 22,000 10% Agency Generated Revenue(fees) $ 2,000 $ 2,000 0% Local Government Grants: Orange County $ 1,250 $ 1,000 -20% Town of Chapel Hill $ 1,250 $ 1,250 0% Town of Carrboro $ 1,250 $ 1,250 0% 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: $ - $ - $ - 0 Other Grants: $ - $ - $ - 0 Miscellaneous/Other Revenue $ 9,500 $ 2,500 $ 2,750 10% Please list 3 largest Miscellanous sources: IBM Community Grant $ 2,500.00 Earwheels Bike Club(restricted $ 2,500.00 DHC Youth Forward(restricted $ 4,500.00 Total Agency Revenue $ 41 298 $ 28 250 $ 33 250 18% AGENCY EXPENSES Compensation $ - $ - $ - 0 Rent&Utilities $ 4,050 $ 3,000 $ 3,300 10% Supplies&Equipment $ 927 $ 1,000 $ 1,100 10% Travel&Training $ 247 $ 750 $ 825 10% Other Expenses: $ 13,940 $ 13,940 $ 15,334 10% Please list 3 largest"Other Expenses": Contract Services $ 3,993.00 Facilities and Equipment $ 3,936.00 Insurance and Other Expenses $ 6,011.00 Total Agency Expenses $ 19,164 $ 18,690 $ 20,559 10% SURPLUS/(DEFICIT)FOR PERIOD: I$ 22,134 I$ 9,560 I$ 12,691 I 33/ Main Application 5/25/2016 10:17:47 AM P o of 2 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application MAIN APPLICATION Program/Project Description b) Summary:Triangle Bikeworks offers youth cycling programs that are focused on education, personal development and achievement within the Triangle region, the state of North Carolina and the United States. Funding programs of Triangle Bikeworks will accomplish Priority#2 as stated in the Town of Chapel Hill's Human Services Advisory Board Budget Priorities, FY 2016-17, where it seeks to fund education, mentorship, and afterschool programming for youth. Triangle Bikeworks believes that all youth should have the opportunity to expand their physical and cultural boundaries. There are many youth, due to financial or social limitations, that are never exposed to what may provide the greatest source of learning— real life experiences that bring home valuable insights, logical steps for positive change and the opportunity to build important resiliency skills. c) Local Need:Triangle Bikeworks' programs of organized youth cycling are for those who are under-represented in the activity of cross country adventure bike touring and competitive bike racing such as, Cyclocross and Mountain Bike Racing. The majority of youth that are helped by this programming fall within the Black, Latino and Karen populations of Chapel Hill and Carrboro. Chapel Hill and Carrboro are both bike friendly towns with cyclists participating in both urban cycling and commuting as well as venturing into the farm regions of Orange and Hillsborough counties for adventurous distance cycling. Participants in these activities do so for the obvious beneficial reasons of transportation, entertainment and health. While there is no statistical data outlining the lack of participation in cycling by non-White youth it is not hard to perform your own anecdotal analysis of the lack of participation by youth of color. Simply stand on any corner in the two towns on any busy week or in the farm regions of Orange County during the weekend and it will be obvious that there is a lack of diversity. You will find the same small level of participation during Youth Cyclocross and Youth Mountain Bike racing events. As stated earlier in the application "a growing body of research literature finds that, in addition to improved physical health, sport plays a primarily positive role in youth development..." This can also be said of the distance touring. Getting developing youth involved in distance cycling accomplishes several things: ✓ Removes the stigma that those who cycle are poor ✓ Proves that cycling is a viable means of transportation ✓ Allows youth to focus and concentrate easier ✓ Take safety seriously ✓ Allow youth to become more self sufficient It also offers a way into a lifestyle that has lasting benefits for the individual in the way of health and benefits the community by reducing the number of emission vehicles needing to be on the road. d) Population Identification:The population of youth to be served will reside in the Black, Latino and Karen populations of Chapel Hill and Carrboro. By exposing these young people to new Main Application 5/25/2016 10:17:47 AM P I of 2 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 t A - continued Provider's Outside Agency Application MAIN APPLICATION challenges, other cultures and diverse environments through an intense hands-on experience, Triangle Bikeworks believes we can open young people's eyes to new ways of thinking and positively impact them to create positive change in their own lives and communities for the future. e) Location:Triangle Bikeworks will carry out the activities from the offices of 115 W. Main in Carrboro, NC. f)Timeline: It will be July 2016 when the determination of grantees will be finalized. Funding will be for the Spoke'n Revolutions Youth Cycling program, which runs from October 2016 until August 2017. The 2017 tour will be centered on sections of the Trail of Tears; a region stretching from Florida to Oklahoma. Practices for the program will be held weekly. g) Agency's Experience with Similar Programs as the Funding Request Triangle Bikeworks has no experience with other agencies with similar youth touring or project based learning programming. In 2013, Triangle Bikeworks was successful in creating the seed program for the Youth Hammercross Cyclocross program put on by the adults in the men's Hammercross cyclocross team. h) If not funded: Triangle Bikeworks will continue the project with limited funding, less youth, and possibly with personal funds as has been done before. But continue it, nonetheless, because the work is important to those who are in the program. i) Other Pertinent Information Triangle Bikeworks will also be instrumental in the formation of a team of youth participating in the North Carolina Interscholastic Cycling Association's (NCICA) mountain bike racing league. Youth mountain bike racing will begin training and team formation fall of 2016 with races starting spring 2017. Main Application 5/25/2016 10:17:47 AM .. g of 20 DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 EXHIBIT `B" Scope of Services—FY 2016-17 Outside Agency Performance Agreement Agency Name: Triangle Bikeworks Funding Award: $1,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount 2017 summer tour cycling of the Trail of Tears 1,000 Program Services For assistance with this or the following section, please reference the Exhibit A instructions and example, located within the contract and reporting memorandum. Outline the major activities the agency will employ to attain the Anticipated Outcomes below,by June 30,2016. • Provide youth engage in self powered vehicles • Provide youth experience health outdoor activities • Provide youth with a historical view from a different prespective 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 Youth will create compleegin narratives about their tour experience via blogs,journal entries,and 11 youth video diaries. Engage in polling before and after tour to capture transformation 11 youth Youth will share experience with other youth 11 youth DocuSigned by: " %"" "" Executive Director 11/22/2016 Certified by: 58B6EAF3C05248c... Title: Date: (Provider's Signature) DocuSign Envelope ID: D9639255-8147-4A2F-A760-941BDE078E48 TRIANO3 OP ID:AW RL)° DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/19/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Anita Chick (Senn Dunn-High Point PHONE FAX 1400 Eastchester Drive,St 200 ( c,Nch gm 336 878 7800 l i+vice Ndi. 336 841 5319 High Point,NC 27265 �ADDRESS.achick esen ndunn com Small Business Accounts-HP . .... �...... ��...... ................................... INSURER(S)AFFORDING COVERAGE NAIC#...... ....r........... .......,.,.........,.�... INSURER A:Alliance Member Services 10023 INSURED Triangle Bikeworks INSURER B Kevin Hicks PO Box 17202 INSURER C Chapel Hill, NC 27514 INSURER D INSURER E: F........ .,.,. . 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 A D D L ix ... .,. POLICY EFF POLICY EX. ,.., LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) LIMITS A X cOMMERCIAL GENERAL LIABILITY OA EACH OCCURRENCE AGE'T 4 R 9 TEO mm$ 1,000,0001 CLAIMS-MADE X OCCUR 2016-37804 06/11/2016 06/11/2017 PREMi ES(Ea oca rite/1001 $ 500,0001 MED EXP(Any one person) $ excluded ....... ......... PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY JECT LOC PRODUCTS COMP/OP AGG PRO $ 2,000,000 OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT l 1,000,000 LEa accident) A AUTOS AUTOS (Per person) $ ALL OWNED SCHEDULED ANY AUTO (Per INJURY Pe accident)r nt) $ accide NON-OWNED PROPERTY DAMAGE ......; HIRED AUTOS AUTOS „To,act,der..) ,... ...L$. .. ........_ I $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ - CLAIMS MADE AGGREGATE ---....._ EXCESS LIAB ..- $ DED I RETENTION$ $ WORKERS COMP N AT ION TY Y d N .... ... ......................_........... ..,�.�,. PEATUT'E,.m..,..,.,... E0 H- AND ...,..... . .......... ANY PROPRIETOR/PARTNER/EXECUTIVE E .EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A „........... ................. ........ .. (Mandatory i NH) EMPLOYEE $ I If yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT LIMIT $S .......... DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE.HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County (OC) ACCORDANCE WITH THE POLICY PROVISIONS. Allen Coleman 200 S. Cameron Street AUTHORIZED REPRESENTATIVE i �� � Hillsborough, NC 27278 � v ©1988-2014 ACORD CORPORATION. All rights reserved,. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD