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Home My WebLink About2017-078-E DSS - The Exchange Club's Familv Center in Alamance - Outside Agency Performance Agreement Docunign Envelope ID:ABmeoc1-8309-4o41-B52n-6E84ro73FAA6 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 The Exchange Club Center for the Prevention of Child Abuse of North Carolina, Inc.'s The Exchange Club's Family Center io /\lamnnoe, a not-for-profit corporation, located at 200 N. Main Street, Graham, NC 27253 ("Provider"). W1TNESSETH: VVREREAS, 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; NVVV. TBEREF0RE, in consideration of the above and the mutual covenants aid conditions hereafter set forth,the County and The Exchange Club's Family Center in Alamance 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 CoLinty 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$6,175. 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 aLithorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds ar 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 shalt be paid in four equal installments in the amount of$1,543.75. The first payment is contingent upon receipt of the agency's perfonnance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. s Family en*er| Orange County Outside Agency Performance Agreement Revised 8/2016 Docunign Envelope ID:ABmeoc1-8309-4o41-B52n-6E84ro73FAA6 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. 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 3 I; January 1 — March 31 and April } - June 30. Reports are due on January \], April 15, and July 8 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 andlor 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 iN Orange County Outside AXrnu7Pcg0,mumce Agreement Rev 8/16 Docunign Envelope ID:ABmeoc1-8309-4o41-B52n-6E84ro73FAA6 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. 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 ]0 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 Agreem em, 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 i jury, 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 tliereot iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal i jury 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 $|,0O8,00O Each Occurrence Liability $2,000,000 Aggregate • Automobile iobi|ity $500,000 Combined Single Limit • Professional Liability $l,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 8|8l Hillsborough,NC 27278 t14#0.Y 1 ~— Orange County Outside Agency Performance Agreement Rev. 8J0 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 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 The Exchange Club's Family Center in Alamance 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 (t Exchange Club's Family CeMetin*Allamance) Orange County Outside Agency PerfOrmance Agreement Rev, 8/16 Docunign Envelope ID:ABmeoc1-8309-4o41-B52n-6E84ro73FAA6 required andlor made pursuant to this Agreement to be given WtheCountyuodUe Provides shall be in writing and mailed to the party addressed as follows: County: Finance & Administrative Services Provider: The Exchange Club's Orange County Family Center in Alamance Post Office Box 8|8l 200 N. Main Street Billsborougb, NC2727B Graham, NC 27253 16. E Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall ouporycdc, 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 | ]/\ and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and `.he Provider Soor4 — 2/9/2017 --'cB13.734n0s0AF2 Date For and ^.00+46.69BOrange County Government ^^`'-'—` `'--''`~' '~`l 2/I5/2017 Bonnie Harnrnersley, County Manager Doe (The Exchange Club's/Family!Center'in~A&am4ome) Orange County Outside Agency Performance Agieement Rev 8'16 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION APPLICATION SUBMITTAL CHECKLIST FOR OFFICE USE ONLY Received By Agency _The Exchange Club's Family Center in Date/Time Alamance I Complete Y/N Program(s) _Parent Aide Services Section Subsection For CDBG & HOME - HUD Regulations 1. Cover Page a. 14 Applicant Contact Information b. Project/Program Contact Information c. i4 Funding Requests Identified d. X4 Signed Application Cover Page 2. Agency a. 14 Agency's Years in operation 24 CFR 570.506, Information - b. 74 Agency's Purpose/Mission 570.507, 570.610;24 C. A. Agency's Types of Services Provided CFR Parts 84 or 85 d. Agency's Experience a. I Other Pertinent Information 3. Program/ a. Type of Application and Program Identified 24 CFR 570.200(a), Project b. I Summary of Program 570.201-570. 208 Information- 507.503 c. I1 Description of Identified Need (for each d. i1 Description of Population to be Served program/ e. 4 Activity Manager and Location Description project for which funding Activity Implementation Timeline 1* is requested) g' Agency Collaboration h. i4 Describe Impact of Reduced/No Allocation I. L Other Pertinent Information j. ■ Complete Target Population/Beneficiary Chart k. 4 Complete Schedule of Positions I. Signed Conflict of Interest Disclosure m. Complete Work Statement iiPage DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED 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. I Program Budget Worksheet 570.602, 570.607(b), is requested) b. I Program Budget Detail 570.611 24 CFR c. Cost Per Unit 570.502-570.504, d. I Agency Operating Budget Worksheet 570.505, 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. 0 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. i1 NC Solicitation License d. IRS Federal Tax-Exemption Letter 0. 1 Certificate of Insurance f. I List of Board of Directors 24 CFR Parts 84 or 85 g. ii Articles of incorporation/Bylaws 24 CFR 570.208, h. Authorization to Request Funds 570.500(c), 570.611 Authorized official designation j. Solid Waste Program Fee(SWPF) Verification Main Apprication 1/24/2016 4:55:46 PM Page 2 of 21 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION 1. COVER PAGE (Each program requires a separate application.) a) Applicant Contact Information Applicant Organization's Legal Name: The Exchange Club Center for the Prevention of Child Abuse of North Carolina, Inc's The Exchange Club's Family Center in Alamance Applicant Organization's Physical Address: 200 N. Main Street Graham, NC 27253 Applicant Organization's Mailing Address: 200 N. Main Street Graham, NC 27253 Applicant Organization's Web Address: www.exchangescan.orq Executive Director: Cynthia Napoleon-Hanger Telephone Number: 336-748-9028 E-Mail: Cynthia.hangerAexchangescan.org DUNS Number: 171570203 (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: Parent Aide Services Project/Program Primary Contact and Title: Sarah Black, County Director Telephone Number: 336-227-5601 E-Mail: sarah.black@exchangesgan.orq c) Funding Request Identification Total Project/Program Cost $4?, Total Amount of Funds Requested: $23,700 Proposed Use of Funds Requested (2-3 Line Maximum): Funds will be expended on the provision of Parent Aide services in Orange County. 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. El CDBG Non-Construction (CH) $ A Grant EA Loan El CDBG Construction (CH) ED Grant El Loan HOME CHDO (OC) 0 Grant El Loan El HOME Other(OC) Grant 0 Loan Human Services: i1 Carrboro $3000 4 Chapel Hill $10,350 i4 Orange County$10,350 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. Ogfr' Signature: AD, LAIL. r ecutive Dir;cto, - Date Signature d /di„ if ... era r• A,:rpe on Date Main Appliation 1/21/2016 12:08:06 PM Page 3 of 3 Docunign Envelope ID:ABmeoc1�09-4o41-B52n-6E84ro73FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION . ' 2. AGENCY U��FORMA��N Please provide the following information about your agency(Limit of 2 pages total): a) Years in Operation, Date of Incorporation (Mon The Exchange Club Center for the Prevention of Child Abuse of North Carolina, Inc. began operating in October 1981 and was officiall incorporated in February 1981. The Exchange Club's Family Center in Alamance (Family Center in Alamance) has been in operation since 1997 and began services in Orange County in 2004 through its treatment programs. The Exchange Club's Family Center in Alamance was incorporated in May of 2000. In 2001, due to issues of sustaining business viability, the Family Center in Aimmance came under the umbrella of Exchange Club Center for the Prevention of Child Abuse of North Carolina, Inc. b) Agency's Purpose/Mission The agency's mission is the prevention and treatment of child abuse and neglect.The prevention and treatment of child abuse and neglect occurs through enhancing parent child relationships, by increasing community awareness, and increasing community involvement in prevention efforts. c) Types of Services the Agency Provides The Family Center has 7 prevention and treatment programs currently offered to families which include intensive Family Preservation Semioes, Parent Aide Services, Children's Parents parenting classes,Adolescent Parenting Program, Respite Services, ParentiTeen Solutions,and Adolescent Parent S rt Program as well as a 24-hour crisis line and community awareness. Triple P Positive Parenting Program and SafeCmrm Services, evidence-based uuou|umRs, are offered in the context of some home visitation models. The center currently offers programming in 7 counties (Alamance, Orange, Chatham, Person, Caswell, Guilford, and Randolph) in the triangle/triad area with Orange County (along with Alamance County) as one of the primary counties served. Initiarly the Family Center of Alamance opened in 1997 offering the prevention services of Children's ' --n'- parenting classes located at the agency and Parent services (evidence-based) in the home of clients. Children's Parents parenting classes are based on the promising practice curriculum created by the Parent Institute of Exchange Club Child Abuse Prevention Center of N.C., Inc. Parent Aide is the agency's primary program of home visitation services. The Exchange Club's model of Parent Aide se ,icesvvasUgvo|opgdinre to th No�ona/ Exchange ��/ub'eodnpdonof<�hi|d Abuse F�navantionos their national p ject in 1979. Parent Aide home visitation program services are provided to families at-risk of or involved in abuse and neglect. The agency began to panM to additional programming in 1990 through the Adolescent Parenting Pro Teen Pregnancy Prevention Initiative funded bythe~NC Department of Public Health. Services are provided in the home,community, and school to teen parents in order to avoid a second pregnency, prevent abuse and neg|mot, and assist them in graduating from school. The agency expanded into Orange County in 2004 with its treatment service Intensive Family Preservation (EFPS). IFPS services are intensive in-home counseling treatment services for families whose children are at risk of out-of-home placement; it is a program funded the NC Qepa�nnen1oY��oc/a|��arvices.Additional programming was added in 2007- whenthe by Family Center of Hillsborough closed down and the Family Center in Alamance took over provision of Parent Aide Program services in Orange County_ Since that time, Parent Aide services and Children's Parents parenting classes have been offered forat-hahpopubab0noofdli|damuaend neglect in Ora e County through the Family Center. In 2011, the agency added additional teen services through the Adolescent Parent Support Program, serving higher risk teen parents who have dropped out of school. Teen moms and dads are provided with a version of Parent Aide services with an additional focus on sexual hea|th, avoiding additional pnegnancies, and assistance with enrollment into finishing their education. Agency staff were certified in Triple P Positive Parenting Program (evidence-based) services in 2012 and currently operates the Main Application 1/24/2016 4:55:46 PM Page 4 of 21 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION curriculum in various home visitation models such as the Parent Aide Program. In 2013, the agency added on the Parent/Teen Solutions program, a home visitation counseling program and group parent/teen educational classes that serves court involved youth and families funded by Alamance County's Juvenile Crime Prevention Council NC Department of Public Safety. In May of 2015, agency staff were trained in Safe Care, a home visitation service that provides parenting, safety, and health parent coaching to families with children 0-6. Safe Care is currently offered in the Parent Aide program for qualifying families. Finally, the agency added Respite services in 2015 to Alamance County residents to assist at-risk families with finding temporary short term child care during times of stress and crisis. d) Agency's Experience with Similar Programs as the Funding Request The Family Center has 19 years of experience in administering grant funds and providing successful child abuse prevention services in the community. All of the agency's programs are either offered in the home or as parenting classes on site or in the community. The agency has been offering Parent Aide services in Alamance County for 19 years, in Orange County for 10 years, and is expanding into Caswell County in 2016.The Family Center was a part of the original randomized trial clinical study that helped to achieve the program's evidence-based status. The Family Center is very familiar with the dynamics of child abuse and neglect,trauma, and working with at-risk and substantiated families. The agency has been involved in state wide and local initiatives on child abuse education and prevention. Due to the history of offering Parent Aide services in multiple communities, including Orange County families, the staff are experienced at service implementation and goal achievement. The agency is very familiar with the program goals and objectives,the target population, program evaluation, and data collection.The agency - has, and continues,to achieve higher outcomes on preventing abuse, increasing parenting skills, improving problem solving, increasing safety, and linking families to positive supports/community resources.The agency understands how to effectively work with families to put protective factors in place to prevent abuse and neglect from occurring or reoccurring. e) Other Pertinent Agency Information The Family Center has an Advisory Board which works in conjunction with the Board of Directors of Exchange/SCAN in order to manage the agency. The staff of the agency is versed in the complexity of child abuse prevention and has decades of experience in home visitation and parenting education. The agency also operates within a System of Care framework and collaborates on many levels with various community non-profits, for profits, social service agencies, and business. Agency staff sit on various committees, councils, and collaborative efforts. • Main Application 1/24/2016 4:55:46 PM Page 5 of 2 1 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION 3. PROJECT/PROGRAM INFORMATION Agency& Program Name: The Exchange Club's Family Center in Alamance/ Parent Aide Program As you complete your application, complete only those sections that pertain to the type of application you are submitting.The application is divided into several sections and not all sections apply to every project. Every applicant MUST complete the main application. a) Check the type of funding request for this application package submittal and complete the required application and required supplemental sections (Parts) as specified below: Human Services (Main Application Only) CDBG Non-Construction —(Main Application AND Part A) EJ CDBG Construction —(Main Application AND Part A AND Part B) HOME CHDO Set-aside —(Ma In Application AND Part A) El HOME Other—(Main Application AND Part A AND Part B) Indicate the type of program for which you are requesting funding: Disabled Public Housing Program Category Youth Adult Elderly (not elderly) Neighborhoods/Residents Education Health and Nutrition Job Training_ Sports and Arts Activities Pre-School Activities After-School Activities Mentoring X X X X Transportation X X X X Housing Other: Please X specify(Parenting Support) X X Main Application 1/24/2016 4:55:46 PM Page 6 of 2 1 IDocunign Envelope ID:ABmeoc1�09-4o41-B52n-6E84ro73FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION Program/Proiect DescrlDtion (Label your responses as outlined below; not to exceed 3 pages.) Please provide the following information about the proposed program/p 'ectz b) Summarize the program services proposed and how the program will address the chosen Tovw1/Countyprioritv? The Parent Aide program will provide home visitation services to families at-risk for and/or involved in child abuse and neglect. Provision of services will be offered to ail Orange County residents for free. The goals of the in-home Parent Aide services include (1) increased safety of the child(ren), (2) increased parenting skills, (3) increased problem-solving skills, and (4) increased social support. Parent Aide in-home services last from 6 to 18 months with an average of 9-13 months before the family reaches its goals. Service activities include parent education, coaching, role modeling/ nnentonShip, assistance with concrete supports, case managenlent, advocacy, and assistance with transportation needs. Various evidenced-based curriculums are used to support service activities. The Parent Aide model is evidence-based and is currently listed on the California Evidence-Based Clearinghouse for Child Welfare's list as a Level 3 "Promising Research Evidence" status. The Parent Aide program provides services to many priority areas of concern for the community including: direct parent coaching and mnentorahip; child mentorship to address abuse and neglect dynamics; life skills/ money management skills and concrete supports which collectively increases access to safety-net services for families; transportation and other basic need issues(like food and housing); and increased positive health outcomes for families. Trauma histories have been proven over the last 30 years to lead to lower brain functioning, mental health iooues, and physical health issues so addressing trauma means improving health Vvvwm.cdo'.oy/ace/indmx.hhn). 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. Currently there is no accurate means or precise formula to measure child maltreatment risk within a population, however, examining child abuse and neglect data is often the standard measurement of the cumulative toll of these risk factors on families. From July 2014 to June 2015, there were 1.115 children reported for child abuse and/or neglect in Orange County. This number is increased from the 2013-14 reporting year of 984 children reported (Duncan et al., 2016). Of the 1,115 children reported for abuse/neglect, 38.5796 of them were between the ages of 0-5. As of December 2015 there were 99 children in foster care in the county (Duncan et. al, 2016). It is estimated that these rates of reports are even higher than documented. This child maltreatment data and the nature of under reporting within communities speak to the need for population targeted intervention services in the County to address the issue of child abuse and neglect in the county. The program will directly address these statistics by providing interventions to help families avoid new or repeat involvement with the child welfare system. Child abuse costs the nation $220 million every day (Prevent Child Abuse, Cost Data, 2012\. Children that end up in the foster care system often stay in the system longer than a year increasing the cost for taxpayers. From July 2014 to June 2015, 64.66% of the children that were in the Orange County foster care system remained in the system for over a year (Duncan et. al, 2O1O). Numerous environmental factors can contribute to abuse and neglect(Children's Bureau,2006). Factors include povorty, substance uae, mental health disondens, domestic violence, and access to social supports. Overall Orange County appears to have the following community concerns: insufficient basic needs; traneportation, need for financial stabilit mental illness/subst nce abuse rates and need for services; and domestic violence rates (Orange County Health Report 2011). Orange County has 14.1%of its people living in poverty according to the 20014 U.S. Census Bureau. The Small Area Income and Poverty Estimate [SAIPE] by the U.S' Census Bureau shows that Orange County has 13.1% of the youth living in poverty. In Orange County, 9.8% of the population are Medicaid eligible (NC DHHS, Division of Medical Assistance [DMA], 2015). Though Parent Aide services cannot wholly improve financial status, we will assist families with supports that will help to buffer the risk of abuse and neglect from factors relating to poverty. For example we can reduce Main Application 1/24/2016 4:55:46 PM Page 7 of 2 1 Docunign Envelope ID:ABmeoc1�09-4o41-B52n-6E84ro73FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION barriers to services and success by helping families to secure adequate hoWsing, assisting with budgeting and effective household management, and helping families access and utilize concrete forms of resources and assistance such as TANF, local food pantries, mtu., when applicable. Impoverished communities may lack positive informal and formal support systems for families, such as easily accessible health and mental health aenvicea, social support, and programs to assist children and youth (DePanfilis, Office on Child Abuse and NegNsct, 2006). Reclaiming Futures of Orange and Chatham counties report that at least 2096 of those youth served in Dept of Juvenile Justice system have mental health and/or substance use problems /2012\. Domestic Violence brings a risk of trauma exposure to children in homes of the families experiencing this problem, which leads to long terni consequences of@buse/neg|eo1. |n2O13-2O14 there were 1.542domestic violence calls, 360 clients were provided with domestic violence services, and 1,252 calls and 457 clients served due to sexual assault (North Carolina Council for Women, 2013-14). Studies have found abused and neglected children to be at least 25 percent more likely to experience problems such as dg|inquenoy, teen pregnancy, low academic achievement, substance abuse, and mental illness (Kelley, Thornberry, & Smith, in U.S. DHHS Child Welfare Gotevxoy, 2012l. As abused and neglected children develop, studies show that they are 11 times more likely to be arrested for criminal behavior as a juvenile, 2.7 times more likely to be arrested for violent and criminal behavior as an adult, and 3.1 times more likely to be arrested for one of many forms of violent crime as juveniles or adults (English,Widom, & Brandford, 2004). Delinquent rates in 2014 in Orange County of youth 6-15 is 11.74% (DPS County Databook, 2014), Although not a given, abusive parents often have experienced abuse during their own childhoods. It is estimated that approximately one-third of abused and neglected children will eventually abuse or neglect their own children (Prevent Child Abuse New YoMh, 2003). Parent Aide services address these risk factors directly in the home by providing concrete parenting eduoaUon, case managemmnt, and advocacy to assist families in finding needed services to address mental health and substance abuse, and transportation assistance. d) Describethe population to be served or the area to benefit and indicate how you will identify beneficiaries. Thetargetpopu|et|onofPonantAidePnzgmannserv|cesis18fanm||ieS (9vviththe$efundm) inOnanga County (4), Chapel Hill (4), and Carrboro (1) at risk of and/or involved in abuse and neglect. These families include various socioeconomic backgrounds and will match the diversity of the County (76.8% white, 12.2% B|aok, 8.46 Hispanic/Latino, and 7.7% Asian per the 2014 US Census). Marketing to county referring sources (Dept. of Social Services, Dept. of Public Health, Schools, Non-profits, Fnr-profita, businesses, mental health companies, churches, local mental health entity, etc.) will allow the agency to solicit referrals for families needing services. Self-referrals made by parents in the community will be solicited by general agency marketing efforts(social media,website, etc.). Beneficiaries are identified when the referral is received and the family agrees to services. Qualification for services (identified beneficiaries)will be determined by families that meet at least 3 risk factors on the risk scale. 0) Who specifically will carry out the activities and in what location will they be carried out? Home visits and the interventions used in the visits will primarily occur in the homes of the clients, although community/school visits can occur in goal achievement when providing help with concrete support items. The staff that will implement the program includes bachelor level professionals with experience in social vvorh, counseling, or human services. Current staff have extensive training in child abuse and neglect, trauma, protective factors, substance abuse, mental health, system of care, Strengthening Families curriculum, Safe Cmpe, Triple P curriculum, motivational interviewing, and other pertinent trainings that are helpful in working with this target population, All staff are provided both internal and external training opportunities to increase their capacity to effectively serve the client populations. Volunteers, or paraprofessionals can be used under the supervision of the Parent Aide Supervisor.The current Program Supervisor, acts as the agency's County Director.The County Director has a Masters degree with 10 years of executive level management and administration Main Application 1/24/2016 4:55:46 PM Page 8 of 2 1 Docunign Envelope ID:ABmeoc1�09-4o41-B52n-6E84ro73FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION experience, 11 years of programmatic administration and implementation, and over 15 years of clinical and service delivery experience. f) Describe specifically the period over which the activities will be carried oUt, the frequency with which the activities will be carried qu{. and the frequency with which services will be delivered. Include an implementation timeline. Implementation of programming will begin immediately as Parent Aide services already exist on a smaller scale in the county due to current funding levels. Home visits for programming occur weekly and last anywhere from 1-4 hours depending upon the risk level in the home. Families are enrolled into services for a minimum of 6 months and a maximum of 18 months wfth a 13 month average. g) Provide a bulleted list of other ogmnoieS, 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 coordinatedlcollabor-ative efforts. • Department of Social Services and Department of Health: The agency also collaborates with the departments on Child & Family Team Mmetingu, Permanency Planning rneet(ngs, and has collaborated in the past on funding for services in the county. The agency also works closely with the department to access needed governmental services such as Medicaid, Housing, and TANF funds. Both departments also provide the agency with referrals of families that need services. Currently the agency has a Memorandum of Agreement with Orange County's Department of Social Services over a treatment program offered by the agency in the county. • Department of Juvenile Justice and Orange County Court System: Both have also served in collaboration with our agency by also submitting referrals for assistance with client families dealing with issues of neglect and abuse. Court counselors and lawyers work with the agency through child and family team rneet|ngs, court heaMngm, and other collaborations to ensure client success in treatment. • Orange County I Chapel Hill School System / UNC-Chapel Hill: Schools within the system are inopo�antfor ideDtif�ngtsrnilieaat-hskphmrtninuo�onoentin child xva�argsvgtems. Schools play a key role inagoisUOQ the agency im targeted marketing 0Omninghtvor disadvantaged populations in the county. The University of NC-Chapel Hill works with the agency in providing Master's level Social Work Interns to assist the agency in providing volunteer Parent Aide services in Orange County. • Mental Health/Social Service Agencies/Local Mental Health Entities: All these have become more prevalent in making referrals and providing access to services client families might need to achieve their goals. • Exchange Clubs/Churches/Business: These entities assist the agency by providing monetary Uonationa, concrete donations for items needed by families, and volunteers for serving families in Orange County. h) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If the full funding request was not allocated to the agency, the agency would reduce the number of clients served, apply for matching funds, and reduce the number of hours of the position. i) Include any other pertinent information. Previous research on the evidence-based Parent Aide program has estimated the cost per family (for the total number of months of service) is on average$2,700 per family. The Parent Aide program is a very cost effective competitive service for preventing child abuse and neglect. Most other interventions are short in duration (4-8 weeks)and cost anywhere from $6,000-12,000 per family. Main Application 1/24/2016 4:55:46 PM Page 9 of 2 1 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION Proorarn/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: 0 Persons i4 Households E Units Program: Parent Aide Services Program Beneficiary Demographics Actual Estimated I Projected 2014-15 2015-16 2016-17 Gender 7 families 8 families 18 families Male 13 14 28 Female 16 11 24 Total 29 25 52 Of the females, how many are single- female Head of Households(Omit for Human Services) Ethnicity African-American FT— 4 10 American Indian or Alaska Native 0 Asian 0 Caucasian 6 12 34 Native Hawaiian or other Pacific Islander 0 Other 21 9 8 Total 29 25 52 Of the above, how many Hispanic/Latino 19 9 8 Of the above, how many non- Hispanic/Latino 10 , 16 44 Total 29 25 52 Age 0-5 years 5 7 14 6-18 years 13 8 18 19-50 years 11 10 20 -- ----- Main Application 1/24/20164:55:46 PM Page 10 of 21 =a. DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION 51-61 years 0 0 62+years 0 0 0 Total 29 25 52- Geographic Location Durham City 0 0 Durham County 0 0 Carrboro 0 0 6 Chapel Hill 13 12 18 Chapel Hill Public Housing Residents 4 0 4 Orange County 12 13 24 Raleigh _ 0 0 Wake County 0 0 Total 29 , 25 52 Income Level-See following chart (Omit for HS) <30%Area Median Income 31-50%Area Median Income 51-80%Area Median Income >80%Area Median Income Total 0 0 0 Special Needs (Omit for HS) Elderly(Over 62) Disabled(not elderly) EM. Homeless People with HIV/Aids Total 0 0 0 Main Application 1/24/2016 4:55:46 PM Page 11 of 21 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION CDBG &HOME ONLY- Area Benefit Activities (infrastructure and Public Facilities) _ Street Census Tract Block Grou• , Total Persons #LMI Persons 2015 Area Median Family income Limits U.S. Department of Housing & Urban Development (HUD) 2015 Area Median Family Income Limits Effective March 15, 2015 Income 1 2 3 4 5 6 7 8 Level person people people people people people people people 30% AMI $14,150 $16,200 $20,090 $24,250 $28,410 $32,570 $36,730 $40,890 50%AMI $23,600 $27,000 $30,350 $33,700 $36,400 $39,100 $41,800 $44,500 80°/0 AMI $37,750 $43,150 $48,550 $53,900 $58,250 $62,550 $66,850 $71,150 100% AM! $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.prq/portalidatasets/ii/i115/FY2015 IL nc.pdf Main Application 1/24/2016 4:55:46 PM Page 1 2 of 2 1 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED 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 FT % E* Actual Estimated Projected %Total (R) *= Position Proa Retirement * -ram 2014-15 2015-16 2016-17 Budget Vacant Staff+ Plan (H) Health Plan . Orange County Parent Aide 1.0 11% 3,178 5,475 1 42 000 8% H Home Visitors 6.5 72% 228,102 288 354 287 524 55% R and H Administrative Professional .5 6% 14,255 14,255 14,683 3% Alarnance Director 1.0 11% 59800 61,640 63,517 12% R and H Volunteer Parent Aide Orange .15 15% 0 0 0 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 1/24/2016 4:55:46 PM Page 13 of 21 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED 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 E a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? Li X4 b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? Li c) Current beneficiaries of the project/program for which funds are requested? r 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: Itailkha9 4-cutive Di ect4 Date Adissio Signature: dr. .// ANV6' :oar, airpe on Date Main Application 1/21/2016 12:08:06 PM Page 14 of 1 4 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED 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 Application 1/24/2016 4:55:46 PM Page 1 5 of 2 1 Docunign Envelope ID:ABmeoc1-8309-4o41-B52n-6E84ro73FAA6 EXHIBIT AGEN��/ 4PPL|CAT|F\N [�(�NT|NUED � MAIN APPLICATION Actual Estimated Projected 2014-2015 2015-2016 3018'2017 6to18 month home 6 to 18 month home 6ba18month home visitation instruction visitation instruction visitation instruction , Program Activity 1 (weekly) (weekly) 80%of parents will 80%of parents will 80%of parents will increase parenting skills increase parenting skills increase parenting skills and parent/child and parent/child and parent/child interaction,ehance interaction,ehance interaction,ehance home safety and home safety and home safety and parental supervision, parental supervision, parental supervision, increse problem-solving increse problem-solving increse problem-solving skills and family skills and family 5kills and family functioning, and functioning,and functioning,and increase linkages to increase linkages to increase linkages to social/community social/community social/community Program CoaI supports. supports. ,supports. Protective Factors Survey(Retrospective Protective Factors Protective Factors Post), North Carolina | � Survey(Retrospective Survey(Retrospective Family Assessment Scale Post), North Carolina Post), North Carolina (Pre, Mid,Post),Adult Family Assessment Scale Family Assessment Scale Adolescent Parenting (Pre, Mid, Post),Adult (Pre, Mid, Post),Adult Inventory(Pre/Post , Adolescent Parenting Adolescent Parenting Safe Care Pre/Post PCI Performance Measures Inventory(Pre/Post) Inventory(Pre/Post) and Safety Assessments. � 10O%offamiUes 93%of families will increased parenting increase parenting skills skills and parent/child and parent/child Program Results interaction. interaction. NA 6to1Q month home visitation instruction Program Activity 2 NA New Goal in 2016-17 NA New Goal in 2016-17 (weekly) 80%of parents will improve their capacity to maintain their child1s Goal health. - - SafeCare Home Visitor Performance Measures Hea|th�ssessment. Program Results NA Program Activity 3 Dmarnwn�� DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED 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 1/24/2016 4:55:46 PM Page 17 of 2 1 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION Program Budget Agency/Program The Exchange Club's Family Center in Alameneei Parent Alde Services Actual Estimated Projected Percent AGENCY REVENUE 2014-15 2015-16 2016-17 Change Private Donations $ 1,500 $ 1,500 $ 2,500 67% Agency Generated Revenue(fees) 0 Local Government Grants: Orange County $ 2,000 $ 2,000 $ 10,350 418% Town of Chapel Hill $ 3,427 $ 6,000 $ 10,350 73%l Town of Canton) $ 1,000 $ 3,000 200%1 Other Local: 0 Other Local: 0 Other Local: 0 If more than 3 seurcos,please provide a separate list. Non-Local Government Grants Triangle United Way Ii Slate Government Federal Government Other Grants:Duke Endowment .1111 $ 23,700 0 Other Grants 0 Miscellaneous/Other Revenue 1.1.11.1111.1111 0 Reese list 3Iargest Miscellanous sources: Total Agency Revenue $ 10 500 49 900 AGENCY EXPENSES Compensation $ 3,178 MI $ 42,000 667% Rent&Utilities $ 1,552 $ 900 $ 3,000 233% Supplies&Equipment 31 $ 450 $ 900 100% Travel&Training $ 1,566 $ 3,675 $ 4,000 9% Other Expenses: 0 Pease list 3 largest"Other Expenses": $ - Total Agency Expenses IM 10,500 49 900 MI SURPLUS/(DEFICIT)FOR PERIOD: $ 600 ri 0 $ 100% Main Application 1/24/2016 4:55:46 PM Page 18 of 2 1 11111. DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION b.) Program Budget Detail What is the cost to deliver your projectiprogram? 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 Counselin! Class , ,,, , ,,,, , , . ,....,,,fif, 41,.. t,, Itilrawi:imif 4,, ,,, M ,,,"01'''.;:t.-,reA447,,,,,,y,x' ,?, . , _..,,,,,,, PoskeleFein4.-*,- 1,,kv IN'' 3wr. ''-. ,,,, ".... 14f. , 4(41,0 ji -11 )41‘ *..''' ! -• Pre''''. 4! i I gl4uwial1N,' :',1; ..':::'''' C; a' W"a ' ,,,t_.,, ..:htl!:;4 .4 "1 a .S 1"...Lirat,&Li& 1 13p,: ,I., , Credit Counseling Teacher in class $25 96 hours(8 hrs/mth x 12 months) $2,400 Credit Counseling Teacher—class prep $25 1 48 hours(4hrsImth x 12 mths) ._....._ $1,200 Credit Counselor--one-on-one $20 120 hours(10 hrs/mth x12 mills $2,400 Materials $25 120 course packets/credit reports $3,000 Total $9,000 _ 11 Com 0 lete the table below for the .rciectioro•ram for which ou are res uestin• funds. Attach additional rows/pages, as needed. Program: Parent Aide Services -o.t t,Elements''''','%"t,,7;','`..4 0jpoilMFtrf; tiMPPOPt rheasure,',,' ;(4 'Sliblvtgli ($) Home Visit $63.64 4 per mth X 18 families $49,900 - . __ ' Total , $49,900 . C.) Cost per Unit .,i-_ , , ° ° , ° , ,,T 'wi,' : 4 ' O''qa111 ' A''191'''', g - .,,,- ,,' i, i.„,O. ., •4,Fi.piecteli ,20M17 Total Cost of Program $6,327 $10,500 $49,900 Total #of Units 121 194 784 Cost Per Unit $52.29 $54.12 $63.64 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 112412016 4:55:46 PM Page 1 9 o f 2 1 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED 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 1/24/2016 4:55:46 PM Page 2 0 o f 21 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION CONTINUED MAIN APPLICATION Section Vi.Financial Data Operating Budget for Entire Agency AGENCY NAME: The Exchange Club's Family Center in Alarnance Actual Estimated Projected Percent AGENCY REVENUE '201445 2015-16 2016-17 Chan e Private Donations $ 5,189 $ 4,118 $ 5,000 21% Agency Generated Revenue(fees) 0 Local Government Grants: Orange County $ 2,000 $ 2,000 $ 10,350 418% Town of Chapel Hill $ 4,000 $ 6,000 $ 10,350 73% Town of Carrbnro - $ 1,000 $ 3,000 200% Other Local: Alornonco United Way $ 18,000 $ 18,000 5 25,000 39% Other Local: 0 Other Local: 0 t rrore than 3 souroes,please provide a separate Int Non-Local Government Grants Triangle United Way EMMM $ $ 0 State Government $ 353,014 $ 414 861 $ 373,379 -10% Federal Government - $ - $ Olher Grants:Duke Endowment - $ 42,250 $ 85,000 101% Other(in-ants: 0 Miscellaneous/Other Revenue $ 2,400 $ 10,500 MI Reese list 0 largest Macs lariats so.irces: Special Ewalts 5 2,400 00 Total Agency Revenue $ 490 629 522 579 MEP AGENCY EXPENSES Compensation $ 305,335 $ 369,724 $ 407,724 10%, Rent&Utilities $ 22,361 $ 27,258 $ 28,218 Supplies&Equipment $ 6,291 $ 9,151 $ 9,252 1% Travel&Training $ 30,033 $ 30,960 $ 35,000 13% Other Expenses: S 33,461 $ 53,546 $ 42,385 -21% Reese list 3 Largest'aier Expenses". Grants&Assistance $ 12,625..00 Contractual $ 17,640.00 Fees&Depreciation Expense: $ 11,441 33 Total Agency Expenses 490 629 S 522 579 SURPLUMDEFICIT)FOR PERIOD: I$ (14,1394$ 01 S - [ -10074 Main Application 1/24/2016 4:55:46 PM Page 2 1 of 2 1 Docunign Envelope ID:ABmeoc1-8309-4o41-B52n-6E84ro73FAA6 Exhibit B Provider's Revised Scop of Services and Program Budget Scope of Services— FY 2016-17 Outside Agency Performance Agreement Agency Name: The Exchange Club's Family Center in /\|ucuunoo Program Name: Parent Aide Services Funding Award: $6,175 Outline how the agency will spend Orange County's funding award. Expense Description Amount Salary and 8cnufi $|�s '8VO Mileage $4,222 Rent and Utilities $153 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 in-home visitation to 5 families through the Parent Aide program. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of riuniber of persons/units served within 9rane County,only (all Towns and municipalities), lf you use percentages,you must also provide the total number of participants within that measure's description v,for:m earlier pcdo,mo/�cmeasure. Anticipated Performance Measures Results Number of(unduplicated)families enrolled in Parent Aide in-home visitation services and 6 receiving weekly visits to reduce the risk of child maltreatment. Average number of hours for weekly visits for families enrolled in Parent Aide program. ] Average number of months families are enrolled in Parent Aide program. 13 Percent of families who will increase parenting skills and parent/child interaction. 80% Percent of families who will enhance home safety and parental supervision. 80% Percent of families who will increase problem-solving skills and family functioning. 80Y4 Percent of families who will increase linkages to social/community support. 80% Percent of families who will improve their capacity to maintain their child's health. 80% - -- 's Family Centerin,AlaMon<4 Orange County Outside Agency Performance Agreement Rev. 8/16 Docunign Envelope ID:ABmeoc1-8309-4o41-B52n-6E84ro73FAA6 ATTACHMENT "A" Orange County Certifications—F1' 20]6-|7 Outside Agency Performance Agreement Chief Contact Administrators,Chief, \oertifv that I have provided u list of the chief contact.udmiois�unr `ch�texeuut�eoffiucrundohief �nunci�u] officer for my agency with this Agreement and that| will keep k current tu the County ofOrange. 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 T certi 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. o"""»m"°^^'' county Di rector 2/9/2017 Certified hy: � Ti\l�� Date: (Provider's Signature) rthoo'eligoge club's Fail*(01(erfOi4ilorPonce) Orange County Outside Agency Performance Agreement Rev 8 16 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 ACC•R Et CERTIFICATE OF LIABILITY INSURANCE DATE`MM'DD"m" 4/25/2016 TI-US 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 poiicy(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 C6}INAId7A E; TI racie Hawkins The Phoenix Company, LLC iCNN Exri: (336)765-9332 7 CF ry Nol:(336}765-7141 P.O. Box 26396 ADpa x,tracieh @thephoenic mpany.com ..... INSURER(5)AFFORDING COVERAGE NAIL N Winston-Salem NC 27114-6396 INsuRERABerkshire Hathaway Specialty 22276 INSURED INSURERS; Exchange Club Center for the Prevention of INSURER c: - Child Abuse of North Carolina INSURER 0: 500 West Northwest Boulevard INSURERE: Winston-Salem NC 27105 _INSURER F: , COVERAGES CERTIFICATE NUMBERCL1642549305 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. NSA ADDL SUER POLICY CFP pQ_u� v EXP LTR TYPE OF INSURANCE INSR VIVO POLICY NUMBER (MMIDDJYYYY) (M LIMITS GENERAL LJABILnY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LABILITY prianI E70 RENTED 1 000,000 PR�r11SES(Ea occurrence) $ , A CLAIMS-MADE I X 1 OCCUR 478PR14916101 4/12/2016 4/12/2017 ME.DEXP(Any one person) $ 20,000 PERSONAL&ADV INJURY $ 1,000,000 GENCICAL AGGREGATE $ 3,000,000 GEM_AGGREGATE LIMIT APPLIES PER: } j, PRODUCTS-COMP/OP AGG $ 3,000,000 X POLICY 7 IFC"T LOC 1 4 � $ AUTOMOBILE UABtLI1Y lO MGIHE SINGLE LIMIT -$ 1,000,000 A X ANY AUTO `t6ODILY INJURY(Per person) 3 ALL OWNED SCHEDULED 7RW814916201 4/12/2016 4/12/2017 BODILY INJURY(Per acciderri) $AUTOS X UwKED ED AUTOS PRO G5cry DA AGE $ UMBRELLA LIAR OCCUR. i EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ • DED , RETENTIONS ( $ WORKERS COMPENSATOR WCSTATU• : OYH- AND EMPLOYERS'LIABILITY V 1 N *p` ,,.. ANY PROPRIETOR/PARTNER'EXECUTIVE- N}A EL EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EA EMPLOYEE $ If yes.describe under DESCRIPTION OF OPERATIONS below ... ,m. E.L.DISEASE-POUCY UMIT $ A Professional Liability 47SPx14916101 4/12/2016 4/12/2017 $.000000 Each Occurrence $3,000,000 Ag A SexAbuse/Molestation Liab 478MM/4916101 4/12/2016 4/12/2017 $'00,000 Each Occurrence $300,000 Aggr DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 501,Additional Remarks Schedule,if wore space Is requited) CERTIFICATE HOLDER CANCELLATION (336)714-9367 adavis@cphs.org SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERS) IN CenterPoint Human Services ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Anne Davis •- 4045 University Parkway AUTHORIZED REPRESENTATIVE Winston-Salem, NC 27106 T Hawkins, CISR/HAWCI � ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 mmnwsi ni Tho Art 11711 name anal Inn's arc.ronl r$ora d marlr raf ARr1Rri DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 0 DATE(MM�IDDlYYYY} A ° CERTIFICATE OF LIABILITY INSURANCE 8,13,2016 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). . CONT PRODUCER NAMEACT Tracie Hawkins The Phoenix Company, LLC IAICNNO Esti: (336)765-9332 (AIG.N01:(336)765-7141 P.O. Box 26396 ADDRESS:tracieh @thephoenixcompany.com INSURER(S)AFFORDING COVERAGE NAIC# Winston—Salem NC 27114-6396 INSURER A Berkshire Hathaway Specialty 22276 INSURED INSURER B: Exchange Club Center for the Prevention of INSURER C: Child Abuse of North Carolina INSURER 0: 500 West Northwest Boulevard INSURERE: _._ Winston-Salem NC 27105 INSURER F: COVERAGES CERTIFICATE NUMBERCL1642549305 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 WTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUER POLICY EFF POUCY EXP TYPE OF INSURANCE LTR INSR WVD POLICY NUMBER IMMIDDIYYYY) (MMIDI))YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ A CLAIMS-MADE -OCCUR 47$PK14916101 4/12/2016 4/12/2017 MED EXP(Any one person) $ 20,000 PERSONAL a ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-C OMP/OP AGG $ 3,000,000 X POLICY JFC LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (La accident) S 1,000,000 X ANY AUTO BODILY INJURY(Per person) S A ALL OWNED SCHEDULED 47RWS14916201 4/12/2016 4/12/2017 BODILY INJURY(Per accident) S AUTOS AUTOS - - - X HIRED AUTOS NON-OWNED _(PPRPERTY nt) $ • UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y!N TORY LIMITS FR ANY PROPRIETOR/PARTNER/EXECUTIVE - N!A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E,L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Professional Liability 47SPK14916101 4/12/2016 4/12/2017 $1,000,000 Each Occurrence $3,000,000 Ag A SexAbuse/Molestation Liab 47$PK14916101 4/12/2016 4/12/2017 $100,000 Each Occurrence $300,000 Aggr DESCRIPTION OF OPERATIONS f LOCATIONS)VEHICLES (Attach ACORD 101,Additional Remarks Schedule,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 Town of Chapel Hill ACCORDANCE WITH THE POLICY PROVISIONS. A North Carolina Municipal Corporation 405 Martin Luther King Jr Blvd AUTHORIZED REPRESENTATIVE Chapel Hill, NC 27514 T Hawkins, CISR/HAWKI ACORD 25(2010105) @ 1988-2010 ACORD CORPORATION. All rights reserved. INS025 fontnn5i 01 The Arnpn name.anri Inn^arc rcnietereri marl,¢of Arnim DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 NC DEPARTMENT OF PUBLIC SAFETY DPSktal JJ NOT FOR PROFIT , BPS CONFLICT OF INTEREST POLICY STATEMENT This document is only required from not for profit organizations ONLY:In accordance with the N.C.G.S. 143C-6-23 (b), every Grantee shall file with the State agency/Grantor a copy of the Grantee's agency policy addressing conflicts of interest that may arise involving the Grantee's management employees and the members of its board of directors or other governing body. The policy shall address situations in which any of these individuals may directly or indirectly benefit except as the Grantee's employees or members of its board or other governing body,from the Grantee's disbursing of State funds and shall include actions to be taken by the Grantee or the individual, or both to avoid conflicts of interest and the appearance of impropriety. Agency conflict of interest policy shall be submitted to the Department of Public Safety(DPS)to avoid any delay with the disbursement of DPS JCPC funds. The Grantee shall submit this form(Not for Profit DPS Conflict of Interest Policy Statement Form DPS 13 001) along with the agency's conflict of interest policy when applyingfor funding. Accordingly, no member or board member of the private, nonprofit entity may receive directly or indirectly, any funds received from the State of North Carolina, except for duly, authorized staff compensation and benefits, and reimbursement for expenses actually incurred in connection with the private, nonprofit entity's business and in accordance with final approved ant agreements. WHEREAS, Exchange Club Center for the.Prevention of Child Abuse of North Carolina,Inc. desires to require its Board of Directors and managing employees to avoid conflicts of interest or the appearance of impropriety in the disbursement of State funds; THEREFORE, no member of the Board of Directors or staff members of said private, nonprofit entity shall participate in the solicitation, negotiation, formation, award, arbitration, modification, or settlement of any contract or grant funded in whole or in part by State funds or of any dispute arising under such contract or grant when,the director or staffmembers stands to benefit, either directly or indirectly,from such grant or contract; PROVIDED, no member of the Board of Directors or staff members shall be deemed to benefit directly or indirectly from any contract or grant funded in whole or in part by State funds if he/she receives only the salary or stipend due to him/her in the normal course of employment with, or service to, said private,nonprofit entity. FURTHERMORE, said private,nonprofit entity has written conflict of interest policies and reporting procedures applicable to board members, staff members and volunteers who have any interest or any authority regarding the resources of the private,nonprofit entity. These policies have been comninnicated to board members, staff members and volunteers and full disclosure has been provided for any possible appearance of conflict of interest that may exist. Form DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement Form structure last revised July 2014 NC Department of Public Safety Page 1 of 3 • DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 empp..:4r1 a"`s�'gav 4, NC DEPARTMENT OF PUBLIC SAFETY , 0-,7 '' NOT FOR PROFIT DPS CONFLICT OF INTEREST POLICY STA'l EMENT The following serves to identify and document any personal interest staff members, officers, and members of the Board of Directors may have This document is also to be used to disclose any transactions that may result in personal,financial,professional and/or political gain at the expense of DPS. The statement requires that all personal relationships that may inappropriately influence (bias) actions be disclosed Relationships be it personal,financial,professional and/or political are required to be disclosed to DPS. Conflict means a conflict or the appearance of a conflict between the private interests terests and official cial responsibilities of a person in a position of trust Persons in a position of trust include staff members or the Board of Directors. Private, nonprofit entities shall make full disclosure by notice in writing to the full Governing Board/Council all conflicts of interest, if"yes" is answered to any of the following: (Check all that apply) YES NO L A Board member is related to a staff member. ❑ 2. A staff member in a supervisory capacity is related to another staff El member whom he/she supervises. 3. A staff member is related to another staff member. ❑ }g 4. A board member or staff member has or may have personal, ❑ financial,professional,and/or political gain at the expense or benefit of the private,non.rof t entit,; 5. There is a business entity in which a staff,board, or family member Q ►1 participates that may be viewed as having direct or indirect influence over the private,nonprofit entity's business. 6. A staff•;board,or family member may be viewed as having direct or indirect financial gain from personal or business investments/interest in real property held by that staff,board,or family member.' 7. A staff or board member received honorarium or other compensation outside of the scope of employment/operations with the private,nonprofit entity that creates or appears to create bias. 8. A staff or board member secured employment with a competitor or other similar private,nonprofit entity. 9. Ongoing,paid consulting work outside of the staff member's ❑ current employment or board member's with your private, nonprofit entity exists. Form DPS 13 001 Not for Profit.DPS Conflict of Interest Policy Statement Form structure last revised July 2014 NC Department of Public Safety Page 2 of 3 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 4.7.,.. .4N. mr---40P-3 NC DEPARTMENT OF PUBLIC SAFETY DpS NOT FOR PROFIT "1......' V DPS CONFLICT OF INTEREST POLICY STATEMENT I. If "yes" is checked to any of the aforementioned items, the JCPC Program Manager and Board Chair must ensure details for any transaction that exists are described and attached to this form. 2. If this statement fails to list a transaction that may exist that is non-financial in nature, please attach details. 3. Details must include at least the name, and, address, or persons involved, and a description of the relationship and the transaction. Note: Failure to disclose any conflict of interest transaction that exists or is potential within your private,nonprofit entity may result in the cessation of any further DPS JCPC State funds. County: Alamance Agency's Name: (Legal Applicant) Exchange Club Center for the Prevention of Child Abuse of North Carolina, Inc. Federal Tax ID#: Private,Nonprofit Entity Name: The Exchange Club's Family Center in Alamance Executive Director's Print George Brya• (Date of Signature) Name: Sign 1/2.4124/ 7 Board Chair's Print Jenni - L. Marti (Date of Signature) -- Name: Sign ioffiralre j /-e ce-- /7 7....."0111■ 41 le Jaime E Ledbetter Sworn to and subscribed before rue on the NOTARY PUBLIC Day o the date of saidezertifi i I tion - —fill■ Forsyth County, NC , 4 iv _ - ,, div, A 7 - (Notary Public EX—pit Co .' /01/8/2 .) Form DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement Form structure last revised July 2014 NC Department of Public Safety Page 3 of 3 DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 EXCHANGE CLUB CENTER FOR THE PREVENTION OF CHILD ABUSE OF NORTH CAROLINA, INC. (EXCHANGE I SCAN) FORSYTH COUNTY POLICY ON CONFLICT OF INTEREST WHEREAS, the varied interests and backgrounds of the Directors, Officers, and Executives of Exchange/ SCAN could result in situations where the giving of service involves a dual interest which might be interpreted as a conflict of interest; and WHEREAS,the service of such Directors, Officers,and Executives should not be rendered impossible solely by reason of duality of interest or possible conflict of interest; and WHEREAS,duality of interest of possible conflict of interest on the part of such Directors, Officers and Executives can most properly be controlled by full disclosure of any such interest and by the abstention from voting on any matter where any possible conflict of interest is or might be thought to be involved, now therefore be it RESOLVED: That the following policy concerning possible duality of interest or conflict of interest on the part of Directors, Officers, and Executives is hereby adopted: 1. All Directors, Officers, and Executives of Exchange/ SCAN, shall scrupulously avoid any conflict between their own respective individual interests and the interests of Exchange/SCAN in any and all actions taken by them on behalf of Exchange/SCAN in their respective capacities; and 2. In the event any director, Officer, or Executive of Exchange/SCAN, shall have any direct or indirect interest in or relationship with any individual or organization which proposes to enter into any transaction with Exchange/ SCAN for the sale,purchase, lease or rental of property or to render or employ services,personal or otherwise, such Director, Officer, or Executive shall forthwith give the Board of Directors of Exchange/SCAN notice of such interest or relationship and shall thereafter refrain from voting or otherwise attempting to affect its decision to participate or not to participate in such transaction. Minutes of appropriate meetings should reflect that such disclosure was made, and that such Director abstained from voting and was not counted for the purpose of determining a quorum; and 3. The foregoing requirements,however, should not be construed to prevent a particular Director from briefly stating his position in the matter, nor from answering pertinent questions of other Directors by reason of the fact that personal knowledge on the matter may be of assistance to the other Directors in reaching their decision; and 4. A copy of this statement shall be furnished each Director, Officer, and Executive who is presently serving Exchange/SCAN, or who may hereafter become associated with Exchange/ SCAN. DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 Exchange CIO CtileRNfirtr TIN brellliml of Child Abuse of North Carolina, Inc. 9 • Date o v. 1/24/2017 To State Agency Heal' iii1.-r.cfP west Boulevard Winston-Salem,N.C.27105 (336)748-9028 FAX(336)748-9030 Certification: www.exchangescan.org We certify that the NF6,:ariiail*:tigqliaiikirtkhvtTaraO3FMViid:ki'tn.,ti: (Organization's Name]does not have any overdue tax debts, as defined by N.C.G.S. 105-243.1, at the federal, State, or local level. We further understand that any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense punishable as provided by N.C.G.S. 143C-10-1. Sworn Statement: Jennifer L,,,;martin[name of Board Chair] and G-o ge'Bryan (name of Second Authorizing Official] being duly sworn, say that we are the Board Chair and' 'gc:.7*IYO0tN,c,Ok(Title of the Second Authorizing Official], respectively,____ of tiaiiii-Ora6reiltdi,f4'01'6`P*6117r6"eitf:EtiktiWiraffiriiiL[Organization's Name]of Wirl*iii5aLervi[City]in the State of NC[State]; and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. 7 Jaime E Ledbetter NOTARY PUBLIC ;•;LetriFh..r Signa 4111•P'' Date m* Forsyth County, NC • I•t- 17 Seco Authorizing Offici., 4a/re Date ON `Alma° glAsioA ' .1ztct9y; onanci ALIVION Title of Second Authorizing Official JellecIPel 3 ewler Sworn to and subscribed before me on the day of the date of said certification. A-. :2 41 My Commission Expires: 10// 72-C) (Nothy Signature and Seal! If there are any questions, please contact the Department of Public Safety that funded the program agreement. If needed, you may contact the North Carolina Office of State Budget and Management, NCGrants@osbm.nc.gov- (919) 807-4795 1 G.S. 105-243.1 defines: "Overdue tax debt. Any part of a tax debt that remains unpaid 90 days or more after the notice of final assessment was mailed to the taxpayer.The term does not include a tax debt, however, if the taxpayer entered into an installment agreement for the tax debt under G.5. 105-237 within 90 days after ,EtNCD Fo ( \\ uty 1,7005 Revised July 18,2006,7/07,9/08,7/10 j. is form i 0 ,.-ctronic format (Microsoft Word document)at http://ncarts.oreigrants/grant-forms/ 4kao, National Exchange Club Foundation For The Partially funded by Prevention of Child Abuse United Way DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 AC°® CERTIFICATE OF LIABILITY INSURANCE DATE{MMIDDIYYYY) k,....---- 9/13/2016 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 Tracie Hawkins NAME: FAX The Phoenix Company, LLC (PpHlONr o.Exn: (336)765-9332 AIC.N01;(336)765-714E P.O. Box 26396 E-MAIL DRE tracieh @thephoenixcompany.COM ADSSI . ..,.... INSURER(S)AFFORDING COVERAGE NAIC B Winston-Salem NC 27114-6396 INSURERABerkshire Hathawa S•ecialt, 22276 INSURED INSURER B: Exchange Club Center for the Prevention of INSURER C: Child Abuse of North Carolina INSURERD: 500 West Northwest Boulevard INSURERE: Winston-Salem NC 27105 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1642549305 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER IMMIDDIYYYYL(MM!DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $A CLAIMS-MADE X OCCUR 47SPK14916101 4/12/2016 4/12/2017 MED EXP(Any one person) $ 20,000 PERSONAL.&ADVINJURY $ 1,000,000 _ GENERAL AGGREGATE $ 3,000,000 GEN'L.AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 3,000,000 X POLICY PRO-.I LOC $ FCT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 ",_ (Ea accident) _.�_. X ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED 47RWS14916201 4/12/2016 4/12/2017 BODILY INJURY(PeraccAdent) I AUTOS AUTOS X NON-OWNED PROPERTY DAMAGE ci $ HIRED AUTOS AUTOS IPer accident)) ....................�______..__ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION .,. WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N TORY LIMITS FR ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E L.DISEASE- EMPLOYEE $ If yes,describe under ........_ - w...— _ ____ DESCRIPTION OF OPERATIONS below E _DISEASE-POLICY LIMIT $ A Professional Liability 47SPK14916101 4/12/2016 4/12/2017 $1,000,000 Each Occurrence $3,000,000 Ag A SexAbuse/Molestation Liab 47SPK14916101 4/12/2016 4/12/2017 $1D0,000Each Occurrence $300,000 Aggr DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,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 Town of Chapel Hill ACCORDANCE WITH THE POLICY PROVISIONS. A North Carolina Municipal Corporation • • - 405 Martin Luther King Jr Blvd AUTHORIZED REPRESENTATIVE Chapel Hill, NC 27514 T Hawkins, CISR/HAWKI <7 ■ ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025l,onnnw nt Tha ernon name and Irwin ara ranicdararl mark of Ar't'1Rrl