Loading...
HomeMy WebLinkAbout2017-477-E Finance - Community Empowerment Fund - Outside Agency Performance Agreement DocuSign Envelope ID: 5D25D6E0-7166-4244-AEA3-02E6A45FD852 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2017, ("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 Community Empowerment Fund, a not-for-profit corporation, located at 208 N. Columbia Street, Suite 100, 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 Community Empowerment Fund agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30, 2018. 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 B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 13750 b. All funds appropriated shall be used for purposes described in Exhibit B. 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 3437.5. 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. (Community Empowerment Fund) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID: 5D25D6E0-7166-4244-AEA3-02E6A45FD852 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 12, April 13, and July 13 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. (Community Empowerment Fund) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID: 5D25D6E0-7166-4244-AEA3-02E6A45FD852 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. (Community Empowerment Fund) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID: 5D25D6E0-7166-4244-AEA3-02E6A45FD852 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 Non-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 $ 13.75 per hour. To the extent possible, Orange County recommends that Community Empowerment Fund 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: (Community Empowerment Fund) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID: 5D25D6E0-7166-4244-AEA3-02E6A45FD852 County: Finance &Administrative Services Provider: Community Empowerment Fund Orange County 208 N. Columbia Street, Suite 100 Post Office Box 8181 Chapel Hill,NC 27514 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. 18. 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. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. 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. 19. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For hdeulf of the Provider 140t, 610t-S1- 9/4/2017 g6f g7Rfi.3fi7t4-45R Date (Community Empowerment Fund) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID: 5D25D6E0-7166-4244-AEA3-02E6A45FD852 For rbmng -,;kalf of Orange County Government 601A It,tf, kV %U"SL 9/5/2017 063799eg-55E477... Bonnie Hammersley, County Manager Date (Community Empowerment Fund) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FY 2017-2018 Outside Agency Funding Application HUMAN SERVICES • ORANGE COUNTY • TOWN OF CARRBORO • TOWN OF CHAPEL HILL Orange County (OC) Town of Carrboro (CA) Town of Chapel Hill (CH) 200 S. Cameron Street 301 W. Main Street 405 Martin Luther King, Jr. Blvd. Hillsborough, NC 27278 Carrboro, NC 27510 Chapel Hill, NC 27514 jI, y ,ate 111,0 lk 1111 J \' 'a''111111 w, �I�11 II 4S�`.r ilal6,"�11p11 @ppw�q iu, ,, .��� .'� " NS4t CARS' 4- �' i DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION INFORMATION Each year, Orange County Government, the Town of Carrboro and the Town of Chapel Hill invite program funding requests from non-profit providers that support the delivery of vital community services. The application process is very competitive and not all applicants will be awarded funding. Recommendations for funding may be for an award amount less than that requested by the applicant. Agencies that are currently receiving funds from Orange County, the Town of Carrboro, or the Town of Chapel Hill local governments, and are also applying for new funds, must be in compliance with all terms of their current agreement(s) and must not have any outstanding audit findings, monitoring findings or concerns as determined by the municipality. Recipients are required to submit written progress reports on their SMART Measures that include: goals, description of activities/challenges, revisions of timelines/budgets, and other relevant information Funded projects will be monitored for progress and performance, financial and administrative management, and compliance with the terms of Performance/Development Agreement(s). Monitoring may involve site and/or office visit(s). Once applications are received, they are reviewed by staff for completeness and eligibility. The applications are presented to a specific application review group, depending on the funding source. The review group will make a recommendation, based on available funding and the priorities identified by the participating jurisdiction. The recommendation is presented to the appropriate Board/Council for consideration and approval. The Board/Council approves/adopts the final allocations. TIMELINE November 15 Funding Application Posted on Websites November 29 Funding Application Workshop Held October 18-January 23 Agency Prepares Application January 10 Q&A Session Held J nu ar 3'1 AppOlol n Sulannss ul ui re ID. March - May Application Review & Agency Presentations June Agency Funding Approval by Board/Council July Contracts Executed & Programs Begin DO NOT SUBMIT THIS PAGE 1/31/2017 11:04:24 AM I' u 3 u 2 or 25 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION SUBMITTAL INFORMATION Welcome to the Outside Agency Common Funding application for local/general funds, which will be distributed through this competitive application process. All entities or organizations requesting funds must complete and submit this application prior to the deadline to be considered for FY 2017-2018 funding. The Application Submittal Deadline is: Tuesday, January 31, 2017 5:00 PM In the event of inclement weather, check the website for each Town/County you are applying to, for further instructions. Please note that late, handwritten, or incomplete applications will not be accepted. (Applications not signed by the Chair or President of the Board of Directors, are considered incomplete.) An application orientation workshop will tentatively be held on Tuesday, November 29, 2016 at 9 AM to Noon to review the application and submittal requirements. SUBMITTAL REQUIREMENTS FOR EACH MUNICIPALITY Human Services— T Carrboro Applications are accepted once a year and reviewed by the Town's Human Services Advisory Commission, which makes a recommendation for funding to the Board of Aldermen for final approval. For more information about the Town of Carrboro Human Services program, see here. Questions and submittals should be directed to: Annette Stone, 301 W. Main Street Carrboro, NC 27510 919-918-7319 astone(c townofcarrboro.orq Submission: ➢ We strongly encourage applications to be single-spaced, with 12-point arial font and normal margins. ➢ Application: One (1) original plus Two (2) paper copies of the application must be hand delivered or mailed to Annette Stone, 301 West Main Street, Carrboro, NC 27510; AND ➢ One Application and Attachments files must be submitted by email. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. DO NOT SUBMIT THIS PAGE 1/31/2017 11:04:24 AM II' age 3 0 t 2 5 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Human Services — Town Of Chapel Hill In 1982, the Town established local funding to support local nonprofit organizations that carry out human service work throughout the community. Applications are accepted once a year and reviewed by the Town's Human Services Advisory Board, which makes a recommendation for funding to the Town Council for final approval. For more information about the Town of Chapel Hill Human Services program, see here. Questions and submittals should be directed to: Jackie Thompson 405 Martin Luther King Jr. Blvd. Chapel Hill, NC 27514 919-969-5081 jhompson©townofchapelhill.orq Submission: ➢ We strongly encourage applications to be single-spaced, with 12-point anal font and normal margins. ➢ Application: Two (2) paper copies of the application with ORIGINAL signatures must be hand delivered or mailed to Jackie Thompson, 405 Martin Luther King, Jr. Blvd., Chapel Hill, NC 27514; AND ➢ Attachments: The application submittal must be accompanied by a flash drive with the application and all attachment files in electronic format. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. Human Services— Orange County For more information about the Orange County Human Services program, see here. Questions and submittals should be directed to: Allen Coleman PO Box 8181 Hillsborough, NC 27278 (919) 245-2151 acoleman©orangecountync.gov Submission: ➢ Email application and ALL Attachments prior to the deadline. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. Please request a delivery receipt of email with application and attachments. DO NOT SUBMIT THIS PAGE 1/31/2017 11:04:24 AM P a g e or 2 5 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency Received By Program(s) Date/Time Section Subsection 1. Cover Page a. ❑ Applicant Contact Information b. ❑ Funding Requests c. ❑ Signed Application Cover Page d. ❑Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. ❑ Agency's Years in operation b. ❑ Agency's Purpose/Mission c. ❑ Agency's Types of Services Provided d. ❑ Agency's Experience with Programs e. ❑ Other Pertinent Agency Information f. ❑ Schedule of Positions g. ❑ Living Wage h. ❑ Agency Budget 3. Program Information a. ❑ Human Services Needs Priority b. ❑ Type of Program A separate Section 3 is c. ❑ Agency Collaboration required for each program. d. ® Summary of Program e. ❑ Description of Identified Need f. ❑ Description of Population to be Served g. ❑ Program Staffing, Capacity, & Expertise h. ❑ Program Implementation Timeline i. ❑ Value of Investment j. ® Impact of Reduced/No Allocation k. ❑ Other Pertinent Information I. ❑ Target Population/Beneficiary Chart m. ❑ Work Statement n. ❑ Program Budget, Detail, &Cost per Individual 4. Attachments a. ❑ Audit: Organizations receiving $300,000 or more in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ❑ NC Solicitation License d. ❑ IRS Federal Tax-Exemption Letter e. ❑ Certificate of Insurance f. ❑ List of Board of Directors g. ❑ Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 1/31/2017 11:04:24 AM II I:' 5 0 r 2 DocuSign Envelope ID: 5D25D6E0-7166-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact_Information Applicant Organization's Legal Name:The Cornmunit y Empowerment Fund Applicant Organization's Physical Address:208 N.Columbia Street, Suite 100LChapel Hill, NC 27514 Applicant Organization's Mailing Address: Same as above Applicant Organization's Web Address:www.communityef.orq Executive Director: Maggie West Telephone Number:1919)270-5730 E-Mail:maggiew@communityef.org Tax ID Number: b) Funding Request List FYI7-18 Human Services(Funding Being Requested— For All all Programs)and the Proposed Use of funds(2-3 lines or less) Program ,e �x chapel Orange Total - Hill H'- s iu" tx 3� z, s '4:-='..!:a .e �, 1' ,-$ if-f':'',1 i#'�' g ma Rt s . t taf # - } , » Advocate Program $11),0130 $20,000 $33,000 Program Coordinators-Salary and benefits F Totals 4 . $10,400 _ $20,000 $33,000 c) To the best of my knowledge belief ail mation in application is true and current. The document and has been di authorized and by the data governing this board of the applicant. Signature: i l — Exectilt Director Date i r f Signature: l?tt tZ'E v C Board Chairperson Date AGENCY INFORMATION 1/27/2017 1:13:44 PM page 6 o f 7 3 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ►;t b) Members of or closely related to members of the governing bodies of the Town of Carrboro,the Town of Chapel Hill,or Orange County? ® ❑c)Current beneficiaries of the program for which funds are being requested? El 4 d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question,please provide a full explanation below. c)CEF has incorporated into our By-Laws the requirement that at least one former or current beneficiary(Member)of our program serve on the Board of Directors at all times. Currently,two Members serve on the Board of Directors.These members of the Board of Directors provide invaluable advice based on their particular experiences working with the organization directly, and like all members of the Board of Directors, sign an annual conflict,of interest disclosure outlining any potential conflicts that may arise based on their dual relationship with the organization. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to 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, gender identity/expression, 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. 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 program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: v I I (1-- Executiv irector Date Signature: ..>�` CtL t cc- t J_'-7 [i'} Board Chairperson Date AGENCY INFORMATION 1/27/2017 1:13:44 PM Page 7 of 2 3 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): 10/2010 b) Agency's Purpose/Mission (no more than a few sentences): The Community Empowerment Fund cultivates opportunities, assets, and communities that support the alleviation of homelessness and poverty. CEF enables and sustains transitions out of homelessness. We offer matched savings accounts, financial education, workforce development, and relationship-based support to homeless and near-homeless individuals. CEF emphasizes a person-centered approach to overcoming crises and building towards long-term possibilities. Through our programs, CEF assists members in gaining employment, securing housing, and building financial security. c) Types of Services the Agency Provides (bullet format): • Job search assistance: Hands-on assistance in resume-building, interview readiness, job application assistance, access to interview or job attire, transportation assistance to interviews and starting employment, and direct employer connections • Housing search assistance: One-on-one support in securing housing, whether moving from homelessness or from unstable/unsatisfactory housing circumstances, including searching for available properties; applying for an navigating affordable housing options; securing deposit and move-in assistance; finding furnishings; and Rapid Rehousing application and case management • Financial coaching: Support for budgeting, saving, understanding credit, building credit, negotiating debts, and filing taxes • Matched savings accounts provided in-house with a 10% match upon completion of coaching requirement and successful attainment of personal savings goal • Open mainstream checking /savings accounts with area financial institutions on-site at CEF • Health insurance enrollment on-site through partnership and collaboration • Legal services on-site through partnership and collaboration • Peer-facilitated classes for homeless and near-homeless individuals, providing the skills, tools and resources necessary to enable and sustain transitions out of homelessness • Linkages to community resources through a wide array of collaborators, including mental health providers, substance abuse treatment, vocational certification, supportive employment programs, veterans services, physical health care, and more. d) Agency's History with Providing These Services: The combined suite of CEF's services has proven to be effective at enabling members to gain employment, secure housing, and build savings. To date, CEF members have saved over$700,000 towards personal savings goals since our savings program began in 2010. Meanwhile, in 2016 alone CEF assisted 155 members in gaining employment and 105 in moving out of homelessness. Our volunteer advocates are a key component of our ability to successfully serve our members, contributing 16,653 hours of volunteer support directly working with CEF members in 2016, making a total in-kind contribution to CEF valued at an estimated $364,356 by the Independent Sector. Agency Information 1/31/2017 11:04:24 AM Page ar 2 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Based on our successful outcomes and unique model, CEF's programs have been evaluated and highlighted by several national organizations, including publications by the Corporation for Enterprise Development (CFED), the Center for Advanced Hindsight at Duke University, FIELD at the Aspen Institute, and a peer-reviewed journal article published in the Journal of Poverty Special Issue on Housing the Homeless. CEF is rooted in a collaborative approach that connects the supportive service networks of Orange and Durham Counties, the two communities in which we work and have offices. We are welcoming connectors, and are committed to cultivating an open network of people and organizations to holistically serve members' goals. Our history and our success in providing these services is based firmly in these connections and partnerships all across our community, and in developing unique services or new collaborations that strive to fill the gaps that emerge in our local support system for individuals transitioning out of homelessness and poverty. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director?Are there new initiatives?) Launch of Orange Community Hub: CEF launched a partnership through our Chapel Hill office to collaborate with private agency, public, and government resources to facilitate integrated service delivery. We relocated our main office to an expanded and more amenable space in order to accommodate a formal co-location of services and build an integrated service delivery model with partners - specifically incorporating the services of partners who provide legal services, mental health services, housing support, and veterans services. Beyond co-location in the physical space, the opportunity for discursive, collaborative, person-centered service delivery that leverages the strengths and capacities of all partners is extraordinarily exciting. Importantly, agencies are not co-locating their primary offices or staff to this shared space, but are providing varying degrees of co-located services depending on the agency and its desired outcomes. For example, an agency might host two regularly scheduled hours for intake or outpatient services on-site at this location, or an agency might simply utilize the shared space on an ad-hoc or as-needed basis. The benefit to CEF members— and more broadly, to the homeless and at-risk community in Orange County— is the opportunity to access critical supports in a streamlined, convenient manner, and to receive better coordinated services across a wide variety of social service systems. Volunteer Training now an Academic Course at UNC School of Social Work: This year we developed a partnership with the UNC School of Social Work and APPLES Service- Learning to offer an academic course that trains our volunteers in financial coaching through a course for academic credit at UNC. This course replaced our current training offering in financial coaching for Chapel Hill advocates, which was not previously available for academic credit. The curriculum is now facilitated by and developed in collaboration with a faculty member in the School of Social Work, and the training series is now significantly longer, with more opportunities for written reflection, reading requirements, and additional content. The course was offered for the first time on the UNC registrar in Fall 2016. This adapts our model at Duke University, in which our overall volunteer training has already been an academic course for two years. f) Schedule of Positions (For Entire Agency) • Full Time Equivalent(FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. Agency Information 1/31/2017 11:04:24 AM Page ar 2 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE - Full-Time Paid Positions: 6 # of FTE - Paid Part-Time Positions: 3 # of Volunteers: 240 # of FTE -Volunteers:8 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? Yes If no, please explain. Agency Information 1/31/2017 11:04:24 AM Page 1 or 2 5 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION h) Agency Budget i. Is your agency currently receiving and/or requesting other(non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) No If yes, please list below: Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY16-17 FY17-18 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro -Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $15,000 Carrboro— Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) Agency Information 1/31/2017 11:04:24 AM Page 11 or 2 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOME/etc.) • Private Foundation Grants o Other Revenue • Expenditures o Compensation o Rent & Utilities o Supplies & Equipment o Travel & Training o Other Expenses iii. Does your agency budget show a Surplus or Deficit? No Is there a significant change?Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. iv. What is your agency's fiscal year? January 1, 2017—December 1, 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/31/2017 11:04:24 AM Page 12 ar 2 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency Fiscal Year:January 1 - December 31 Agency Name: Community Empowerment Fund Actual 2016 Estimated Projected Percent Income 2017 2018 Change Individual Contributions 70,267 90,808 92,409 2% Contract Income (Agency Generated Revenue) 25,609 33,470 33,591 0% Grants 0 Local Government Grants 0 Human Services-Town of Carrboro 1,875 2,375 3,000 26% Other-Town of Carrboro 0 0 0 0 Human Services-Town of Chapel Hill 4,000 7,250 10,000 38% Other-Town of Chapel Hill 0 0 0 0 Human Services-Orange County 7,500 13,750 20,000 45% Other-Orange County 0 0 0 0 Other-Town of Hillsborough 0 0 0 0 Other Government Grants 0 Triangle United Way 0 0 0 0 State Government 0 0 0 0 Federal Government(CDBG/HOME/etc.) 0 0 0 0 Private Foundation Grants 210,000 183,032 183,032 0% Corporate Grants 31,450 56,750 56,750 0% University Grants 26,825 34,500 26,825 -22% Contributions for Direct Member Support 23,520 2,192 0 -100% Rental Income 0 13,400 13,400 0% Fundraising Events 6,510 10,118 11,130 10% Total Income 407,556 447,645 450,137 1% Expenses Matching Savings Contributions 5,453 18,000 19,800 10% Personnel Program Coordinator 36,828 39,950 39,950 0% Operations Coordinator 36,828 39,950 39,950 0% Durham Program Coordinator 31,575 36,751 36,751 0% Advocate Program Coordinator(DU) 23,324 23,333 29,960 28% Housing Stabilization Specialist(DU) 16,955 20,384 21,811 7% Member Services Coordinator(CH) 26,002 33,348 34,682 4% Advocate Program Coordinator(CH) 13,020 30,530 31,751 4% Advocate Program Associate (CH) 10,850 14,560 16,575 14% Opportunity Class Leaders 9,600 10,961 14,928 36% DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Summer Interns 17,500 17,500 17,500 0% Additional Staffing Needs 1,056 5,707 5,707 0% Employee Benefits 11,200 31,323 32,576 4% Payroll Taxes 24,843 24,344 25,771 6% Subtotal: Personnel 259,582 328,641 347,913 6% Contracted Services Accountant 539 4,200 4,200 0% NC Campus Compact Americorps VISTA 6,050 700 0 -100% NC IDA Collaborative Americorps VISTA 7,000 6,200 6,200 0% Additional Americorps 0 5,400 5,400 0% Subtotal: Contracted Services 13,589 16,500 15,800 -4% Supplies and Materials Printing and Copying 3,574 2,960 3,256 10% Food and Drinks 2,778 3,404 3,506 3% Office Supplies 1,544 2,270 2,338 3% Program Supplies 1,554 3,058 3,149 3% Credit Union Account Membership Fees 210 550 550 0% Subtotal: Supplies and Materials 9,660 12,241 12,799 5% Direct Member Support(Reimbursable) 0 HUD Supportive Services 6,080 5,000 0 -100% Designated Direct Member Support 19,646 2,192 0 -100% Subtotal: Direct Member Support 25,726 7,192 0 -100% Operating Expenses Rent, Utilities& Internet 35,481 44,917 44,917 0% Online Services 2,939 2,173 2,239 3% Staff&Volunteer Development 2,362 2,650 2,950 11% Travel and Transportation 2,104 1,030 1,030 0% Course Fees for Advocate Training 0 1,500 1,500 0% Payroll Services 1,216 994 1,024 3% Conferences & Memberships 789 1,100 1,100 0% Postage 1,058 1,100 1,210 10% Other: Bank Charges, Miscellaneous 1,022 488 503 3% Insurance, licenses and permits 1,767 1,118 1,152 3% Subtotal: Operating Expenses 48,738 57,071 57,624 1% Professional Fees Audit&Tax Preparation Fees 8,027 8,000 8,000 0% Other Professional Fees 7,636 0 1,000 0 Subtotal: Professional Fees 15,663 8,000 9,000 13% Operating Reserves 29,145 0 0 0 TOTAL EXPENSES 407,556 447,645 450,136 1% NET INCOME 0 0 0 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Advocate Program Program Primary Contact and Title: Maggie West, Co-Director Telephone Number: (919) 270-5730 E-Mail: maggiew @communityef.org a) Indicate the type of Human Service Needs Priority, if program applicable: ® Priority Area #1: safety-net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing X X X Affordable Healthcare Education Family Resources Jobs/Jobs Training X X X X Food Transportation Other: Please specify c) 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, briefly describe the coordinated/collaborative efforts. CEF partners extensively with other organizations and programs to support the goals of our members in a person-centered and connective manner. In Orange County, some of our key collaborative partners include: Homeless shelters and homeless support services: • IFC (coordinate services for residents of men's and women's shelters; provide in-depth advocate support to residents; connect members to Permanent Supportive Housing vouchers managed by IFC and collaborate to successfully house shared clients) • Orange County Partnership to End Homelessness (system-level coordination of care, including developing new initiatives to address community-level gaps, and coordinating services for most vulnerable homeless individuals through 100,000 Homes Task Force) • Outreach Court (CEF acts as supportive services provider for members referred through Outreach Court, a collaboration of the District Attorney, judicial system, and mental health providers; successful participation by members results in dismissal of charges) PROGRAM INFORMATION 1/31/2017 11:04:24 AM Page 13 or 25 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • VA Hospital HUD-VASH program (shared client case coordination, and integrated assessment of member eligibility for HUD-VASH program to result in increased service connections) • Orange County Department of Social Services Rapid Rehousing Program (contracted by Department to provide case management for Rapid Rehousing clients on-site at CEF in order to expand the reach and capacity of this service in our community) Employment services and workforce development organizations: • Caramore (case collaboration to serve shared clients; integration of CEF's financial services into Caramore's workforce services; coordinated system for referrals to Caramore) • Vocational Rehabilitation (one-on-one support to clients of VR, and streamlined access to application for services at VR for prospective clients) • Chapel Hill-Carrboro Chamber of Commerce (jointly spearheading a county-wide collaboration to support greater strategic coordination between workforce development agencies to address county's workforce needs) Housing programs and providers: • CASA (financial coaching and savings services provided to tenants to ensure ability to pay bills on time and maintain housing) • EmPOWERment, Inc. (financial coaching and savings services provided to tenants to ensure ability to pay bills on time and maintain housing) • Town of Chapel Hill Public Housing (assistance to prospective tenants in navigating the application process; assistance to current tenants in employment and financial goals) • Orange County Department on Housing and Community Development (in-depth advocate assistance in supporting Housing Choice Voucher tenants in securing apartments; coordinated access to supports for security and utility deposits for voucher-holders) Mental health and substance abuse treatment providers: • UNC Center for Excellence in Community Mental Health (connections and coordination across a wide array of mental health services, including co-location of Center services at CEF's office through the Orange Community Hub) • Freedom House (two-way-referral relationship, supporting clients of each respective organization in accessing desired services) Legal services: • Legal Aid of North Carolina (integrated screening for legal services in CEF database resulting in connections to volunteer attorneys and Legal Aid attorneys for legal assistance related especially to issues such as tenant rights, Fair Housing, benefits assistance, and record expunction. Additionally, seasonal programmatic integration for healthcare marketplace insurance navigation). • UNC School of Law (coordination with supervising attorneys and law students through free clinical programs to assess clients' eligibility and make linkages for legal assistance) • NC Justice Center (CEF screens clients for regular criminal record expunction clinics while the Center provides the legal assistance for expunction) Faith-based organizations: • Love Chapel Hill (coordinating to serve the transportation needs of homeless individuals through provision of regional bus passes for job interviews, new employment, medical appointments, and more). • St. Thomas More (addressing emergency financial assistance needs of CEF members while connecting households seeking assistance to ongoing supports for financial capability) Financial institutions: • Self-Help Credit Union (open checking and savings accounts on-site at CEF, facilitating access to financial services for un/under-banked households) • Latino Community Credit Union (open checking and savings accounts on-site at CEF, facilitating access to financial services for un/under-banked households) PROGRAM INFORMATION 1/31/2017 11:04:24 AM Page 11 or 25 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Bank of North Carolina (connect members to checking and savings accounts at branch, facilitating access to financial services for un/under-banked households) PROGRAM INFORMATION 1/31/2017 11:04:24 AM Page 15 f 25 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? Recognizing the need for wrap-around support and the varied circumstances of homeless and near- homeless individuals, CEF's day-to-day operations serve as a one-stop center for individuals and families to connect to comprehensive help. Advocates assist our members with: • Employment: Building resumes, applying for jobs, acquiring interview attire, gaining soft skills, upgrading knowledge, expunging criminal records, and connecting with employers • Financial Capability and Financial Services: Opening bank accounts, building budgets, monitoring expenses, planning for the future, setting savings goals, building credit • Housing: Searching for housing, communicating effectively with landlords, acquiring deposit/move-in assistance, paying bills on time, reducing utility expenses • Community Resources: Connecting to public benefits and to partner agencies to assist with basic needs, emergency food, mental health services, and primary and acute health care These activities combine to create personalized pathways out of acute crisis situations towards greater financial security. In order to best assist members in achieving independence, our advocates continue to support members before, during and after transitions out of homelessness, enabling us to help members realize longer-term dreams of financial stability and security. The CEF Advocate Program is an active, person-centered approach to ending the homelessness of individuals in our local community, and as such, is meeting the Town/County priority of providing safety-net services for disadvantaged residents. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. In the Chapel Hill Human Services Needs Assessment, stakeholders identified "coordination, wrap-around care, and assistance navigating the system" as key strategies to addressing unmet needs. This recommendation was based on the general consensus that "existing human services were unknown, uncoordinated, and therefore inaccessible," resulting in a situation in which "many people do not receive the services they need because they are `unaware' of the full array of services available or do not know how to navigate `fragmented' service systems." Additionally, in the Town of Chapel Hill Affordable Housing Strategy, CEF's work is directly in line with the Town's goals of promoting financial and housing independence for low-income families and transitioning those in shelter to affordable accommodations. Meanwhile, the first goal of the Orange County BOCC is to "ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents." By focusing on the lowest income households in our community, CEF is a key piece of this network in our county. Finally, the Board of the Town of Carrboro sets out to "develop innovative approaches to support the community, particularly with regard to housing, ...". This is a central, shared priority of CEF. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? CEF works with a significantly disadvantaged population. Descriptive characteristics of the CEF member population include: • 72% of members are homeless upon intake • 100% of members earn below 50% of area median income (vast majority <30% AMI) PROGRAM INFORMATION 1/31/2017 11:04:24 AM Page 10 or 25 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • 68% of members are minorities • 30% of members have a disability CEF has built a reputation in the target community as a go-to agency to assist in transitions out of homelessness. Our Columbia Street office reflects these ideals and serves as a welcoming space for homeless or at-risk individuals to seek assistance, connect to resources, or just to escape the elements. We actively reach out to vulnerable and disenfranchised members of the community through our partner organizations and community engagement. CEF is a part of the intake and/or orientation processes in area shelters. We receive referrals through our engagement and collaboration efforts with the wide variety of agencies outlined in the previous section. Our most significant source of referrals remains client-to-client referrals, as 40% of new members hear about CEF from a friend or family member. This source of connection additionally helps to build trust and credibility immediately from the outset of our interactions with new members. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) The program is led by two staff members -- the Advocate Program Coordinator and Member Services Coordinator. The Member Services Coordinator, Diiv Sternman, has 12 years of experience in providing residential and crisis services to individuals experiencing homelessness, focused primarily in services supporting victims of domestic violence and sexual assault. Diiv is a certified SOAR case manager, with training and certification in trauma-informed care and in providing supportive services to victims of domestic violence. Diiv currently serves on the Leadership Team of the Orange County Partnership to End Homelessness, and has served on a number of interagency councils and coalitions to address housing and homelessness, and gender and sexual justice in social service delivery. The Advocate Program Coordinator, Sarah Cohn, has 4 years of professional experience supporting individuals experiencing homelessness in gaining stable housing, in addition to 3 years as a volunteer Advocate with CEF prior to graduating and entering the field. Sarah is bilingual (Spanish and English), and supports the continued growth of our services for Spanish-speaking members. Sarah also has 3 years of experience specifically in volunteer training and coordination. Volunteers delivering advocate assistance to CEF members are trained through a combination of classroom training, year-round continuing education series, and job shadowing. Financial coaching advocates are trained through a semester-long academic course in the UNC School of Social Work. Advocates are directly supervised in their supports for CEF members by CEF staff, as advocate services are provided on-site in CEF's office. Advocates do not provide services in private homes or private spaces, so as to ensure proper safety and supervision. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. The activities of CEF's Advocate Program occur six days a week, year-round. On a daily basis members are able to schedule appointments with CEF advocates to work one-on-one towards their personal goals. The initiatives within the Advocate Program that require an implementation timeline are especially our efforts to conduct seasonal activities, including volunteer advocate trainings which are held three times annually (January, May, and September), along with specialized training tracks in financial coaching (September— December), employment counseling (October — December), and housing advocacy (February — April). Celebrations to recognize the achievements of CEF members are also held seasonally in April, July, and December. i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) The CEF Advocate Program is a multiplier. We act in concert with and as a complement to a wide range of programs to extend the outcomes, impact, and collaboration of other programs. Our Advocates are ultimately helpers and connectors — helping to make sure that vulnerable PROGRAM INFORMATION 1/31/2017 11.04.24 AM Page 1 t or 25 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION community members who are eligible for and in need of services provided in our community are both aware of and successfully linked to those services. By collaborating with professionals in mental health, shelter, workforce development, legal services, and much more, our Advocates are able to provide complementary services that support the ability of these professionals to focus on delivering their uniquely valuable and critical services. Finally, funding the Advocate Program is an investment that undergirds a one-stop center for homeless individuals in Orange County. The Orange Community Hub is increasingly a critical strategy of our Advocate Program. By bringing services on-site and in closer collaboration, the Hub changes a community-level system, which previously necessitated many steps and extraordinary person-by-person coordination for each individual member to connect to certain services. This new strategy, which is more efficient and based on emerging best practices nationally for integrated service delivery, will also result in improved economic outcomes for beneficiaries not just of CEF's programs, but the programs of other agencies as well. For example, studies of a national model found that participants accessing employment and financial services in tandem were 3-4 times more likely to achieve a significant economic outcome. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. CEF's impact in the community has only grown over the years as we continue to serve an ever- increasing number of residents of Orange County on an annual basis. The wrap-around services provided through our Advocate Program, and now with the incorporation of the Orange Community Hub, have made CEF a go-to resource for everything from getting photo identification to finding a home. If the requested funding is not awarded or if a reduced allocation is recommended, CEF staff will doggedly pursue other fundraising activities to ensure that this reduction in the town or county's commitment does not translate into a reduction of services. That said, the increased support of Orange County, the Town of Chapel Hill, and the Town of Carrboro for CEF's work is critical at this juncture. CEF is increasing our request for funding due to two key contributing factors: 1. Growth in impact of services: CEF has grown in the number of Members we serve in Orange County over the last three years, and even more significantly in the scope of our services and the range of community needs we are filling. CEF first received Human Services funding in FY2013-2014. That year, CEF served 446 Members in Orange County. In 2015-2016, we served 691 Members (a 150% increase). Throughout this period of growth we have stretched our general operating resources to meet the mounting demand for our services from partners and Members alike and to effectively scale up to this new level of service provision. In order to sustain our current service levels in the coming year and respond to new opportunities for impactful collaboration, we have defined a need for additional program-specific resources. This application is specifically targeted to meet this programmatic need. 2. Transitioning funding sources: After launching in 2009, CEF became a nonprofit organization in 2011. Since our founding, our innovative, adaptive model has been primarily funded by private foundations and individual donors who have invested to catalyze CEF's development and propel us from a small start-up organization to where we are now -- a strong, growing organization with a model that has drawn national attention and research. Some of these private sources of support are now transitioning out of funding our work, as by moving beyond our start-up phase we have successfully fulfilled our funding objectives and their philanthropic goals. Our rapid growth was made possible in part by the financial investment and capacity-building of these funders. We have now developed an outcome track record and have firmly rooted ourselves in the Orange County community— growing to fill a range of previously unmet needs. We are requesting increased funding from Orange County municipalities in order to sustain CEF's efforts focused on ending homelessness collaboratively and responsively. k) Include any other pertinent information. PROGRAM INFORMATION 1/31/2017 11:04:24 AM Page 1 or 25 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information I) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 308 305 311 Female 248 260 264 Total 556 565 575 Ethnicity African-American 296 299 304 American Indian or Alaska Native 18 19 20 Asian 3 4 5 Caucasian 159 161 164 Native Hawaiian or other Pacific Islander 1 1 2 Other: specify Multi-racial 79 81 80 Total 556 565 575 Of the above, how many Hispanic/Latino 10 11 15 Of the above, how many non-Hispanic/Latino 546 554 560 Total 556 565 575 Age 0-5 years 0 0 0 6-18 years 0 0 0 19-50 years 281 286 290 51+ years 275 279 285 Total 556 565 575 Geographic Location Alamance County 3 3 3 Chatham County 2 2 2 Durham County 21 17 18 Wake County 5 5 5 Orange County Breakdown Chapel Hill Public Housing 17 25 28 Town of Chapel Hill (Non-Public Housing) 387 390 395 Town of Carrboro 99 101 102 Town of Hillsborough 16 16 16 City of Mebane (Orange County) 2 2 2 Orange County(Outside Municipalities) 4 4 4 Total 556 565 575 PROGRAM INFORMATION 1/31/2017 11:04:24 AM P a g e 1 .f 2 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart 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. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program Advocate Program 1. Program Activity Name Assisting homeless and near-homeless individuals to gain jobs Program Goal CEF Advocates will assist 140 homeless or near-homeless individuals to gain employment, through one-on-one support in resumes, job applications, interview preparation, employer relationships, and connections to supportive community resources Performance Measures Assess employment status upon intake and document changes in employment status through weekly meetings and regular follow-up with members. Previous Year Program Results 126 members gained employment Current Year Estimated Results 140 members will gain employment Next Year Projected Results 140 members will gain employment 2. Program Activity Name Enabling homeless and near-homeless individuals to secure stable housing Program Goal CEF Advocates will assist at least 80 homeless or near-homeless individuals to secure housing, through assistance with searching for housing, negotiating with landlords, navigating affordable housing resources, accessing Rapid Rehousing assistance, and securing support for move-in costs. Performance Measures Assess the housing status upon intake and document changes in housing status, determined through regular updates and continued follow-up with members Previous Year Program Results 65 members secured housing Current Year Estimated Results 73 members will secure housing Next Year Projected Results 80 members will secure housing 3. Program Activity Name Supporting homeless and low-income individuals in successfully reaching personal savings goals Program Goal At least 90 members will achieve 25% of their personal savings goal or greater. Savings goals are often long-term goals, and 25% represents a significant step for low-resource households towards PROGRAM INFORMATION 1/31/2017 11:04:24 AM Page 2 .f 2 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION building financial wellbeing. Performance Measures Track deposits and progress towards personal goals in CEF Safe Savings Accounts. The Accounts are managed by CEF, enabling CEF to monitor progress towards goals and successful goal attainment. Previous Year Program Results 67 members made significant progress towards personal savings goals Current Year Estimated Results 90 members will make significant progress towards personal savings goals. Next Year Projected Results At least 90 members will make significant progress towards personal savings goals. 4. Program Activity Name Build the financial capability of homeless and low-income individuals Program Goal CEF Advocates will provide at least 300 personalized financial coaching sessions to support low-income individuals in budgeting, building credit, and improving financial wellbeing. Performance Measures Track the number of coaching sessions completed by CEF Members and Advocates Previous Year Program Results 215 Financial Coaching sessions completed by CEF Members and Advocates Current Year Estimated Results At least 300 Financial Coaching sessions will be completed by CEF Members and Advocates Next Year Projected Results At least 400 Financial Coaching sessions will be completed by CEF Members and Advocates PROGRAM INFORMATION 1/31/2017 11:04:24 AM Page 21 ar 2 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION n) Program Budget 1. Submit your program budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues O Private Donations O Program Generated Revenue O Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other(DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) O Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOME/etc.) • Private Foundation Grants O Other Revenue • Expenditures O Compensation O Rent & Utilities O Supplies & Equipment O Travel & Training O Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. All budget items included in detail. 3. This program budget represents what percent of the agency budget? 40% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program $163,266 $177,971 $182,422 Total # of Individuals 556 565 575 Cost Per Individual $294 $315 $317 PROGRAM INFORMATION 1/31/2017 11:04:24 AM Page 22 or 25 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program Fiscal Year: January 1 - December 31 Program Name: Advocate Program Actual 2016 Estimated Projected Income 2017 2018 Individual Contributions 4,510 12,504 15,272 Contract Income (Agency Generated Revenue) 11,485 15,000 20,000 Grants Local Government Grants Human Services-Town of Carrboro 1,875 2,375 3,000 Other-Town of Carrboro 0 0 0 Human Services-Town of Chapel Hill 4,000 7,250 10,000 Other-Town of Chapel Hill 0 0 0 Human Services-Orange County 7,500 13,750 20,000 Other-Orange County 0 0 0 Other-Town of Hillsborough 0 0 0 Other Governemnt Grants Triangle United Way 0 0 0 State Government 0 0 0 Federal Government (CDBG/HOME/etc.) 0 0 0 Private Foundation Grants 105,000 90,000 84,500 Corporate Grants 8,500 15,000 15,000 University Grants 1,250 1,250 1,250 Contributions for Direct Member Support 19,146 2,192 0 Rental Income 0 13,400 13,400 Fundraising Events 0 5,250 0 Total Income 163,266 177,971 182,422 Expenses Personnel Program Coordinator 16,941 16,941 16,941 Operations Coordinator 11,785 11,785 11,785 Durham Program Coordinator 0 0 0 Advocate Program Coordinator (DU) 0 0 0 Housing Stabilization Specialist (DU) 0 0 0 Member Services Coordinator(CH) 25,482 32,681 33,989 Advocate Program Coordinator (CH) 13,020 28,088 29,211 Advocate Program Associate (CH) 9,982 13,395 15,249 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Opportunity Class Leaders 0 0 0 Summer Interns 7,062 6,000 6,000 Additional Staffing Needs 1,056 1,712 1,712 Employee Benefits 4,032 11,903 12,379 Payroll Taxes 8,944 9,251 9,793 Subtotal: Personnel 98,304 131,755 137,058 Contracted Services NC Campus Compact Americorps VISTA 3,000 0 0 NC IDA Collaborative Americorps VISTA 7,000 6,200 6,200 Subtotal: Contracted Services 10,000 6,200 6,200 Supplies and Materials Printing and Copying 1,358 1,125 1,237 Food and Drinks 1,471 1,702 1,578 Office Supplies 587 863 888 Program Supplies 1,554 1,529 1,575 Subtotal: Supplies and Materials 4,970 5,218 5,278 Direct Member Support (Reimbursable) Designated Direct Member Support 19,146 2,192 0 Subtotal: Direct Member Support 19,146 2,192 0 Operating Expenses Rent, Utilities & Internet 25,728 25,728 25,728 Online Services 1,400 1,500 1,600 Staff&Volunteer Development 900 1,007 1,121 Travel and Transportation 250 250 250 Course Fees for Advocate Training 0 1,500 1,500 Payroll Services 462 378 389 Conferences & Memberships 489 1,100 1,100 Postage 402 418 460 Other: Bank Charges, Miscellaneous 388 300 300 Insurance, licenses and permits 671 425 438 Subtotal: Operating Expenses 30,691 32,606 32,886 Professional Fees Other Professional Fees 156 0 1,000 Subtotal: Professional Fees 156 0 1,000 TOTAL EXPENSES 163,266 177,971 182,422 NET INCOME 0 0 0 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2015, for calendar year agencies, and FY 2015-16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit/report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2014 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990-N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Freuentl Asked Questions Guide PDF , about exemptions. If exempt per N.C.G.S. § 131 F-3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax-Exemption Letter A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 — June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. DO NOT SUBMIT THIS PAGE 1/31/2017 11:04:24 AM II' age 2 3 0 t 2 5 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Limits for Coverage Compensation' A - Statutory State Limits for Coverage A - Limits for Coverage A - NC, for each Statutory State NC, for Statutory State NC, for employee each employee each employee Limits for Coverage Limits for Coverage B - Limits for Coverage B - B - Employers Employers Liability of: Employers Liability of: Liability of: $100,000 Each Occurrence $500,000 each $1 million Each $100,000 BID for each accident, $500,000 Occurrence employee BID for each employee $1,000,000 BID2 $500,000 BID limit $500,000 for BID limit limit Commercial $100,000 Property General Damage Liability $1 million Each Liability $1,000,000 Bodily $1 million Each Occurrence Occurrence Injury Property $2 million Aggregate ry and Pro p y $2 million Aggregate Damage Limit Automobile Not Applicable $1 million Each Occurrence $500,000 Each Liability Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts webpage for more information about the County's risk assessment procedures. f) List of Board of Directors Provide the following information about each board of director's member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. g) Solid Waste Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency's FY 2016-17 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. DO NOT SUBMIT THIS PAGE 1/31/2017 11:04:24 AM II I:' 2 1 0 t 2 5 DocuSign Envelope ID: 5D25D6E0-7168-4244-AEA3-02E6A45FD852 EXHIBIT `B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: The Community Empowerment Fund Program Name: Advocate Program Funding Award: $13,750 Outline how the agency will spend Orange County's funding award. Expense Description Amount Program personnel $13,750 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. Advocates assist our members with: • Employment: Building resumes, applying for jobs, acquiring interview attire, gaining soft skills, upgrading knowledge, expunging criminal records, and connecting with employers • Financial Capability and Financial Services: Opening bank accounts,building budgets, monitoring expenses,planning for the future, setting savings goals,building credit • Housing: Searching for housing, communicating effectively with landlords, acquiring deposit/move-in assistance,paying bills on time,reducing utility expenses • Community Resources: Connecting to public benefits and to partner agencies to assist with basic needs, emergency food, mental health services, and primary and acute health care 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 140 members will gain employment 140 80 members will secure housing 80 90 members will make significant progress towards personal savings goals 90 400 financial coaching sessions will be completed by CEF members and advocates 400 ---DocuSigned by: AitAthit■ 610t,S1- co-Di rector 9/4/2017 96C92B63621415B.. Certified by: ;�,,'e "�'� Title: Co-Director Date: 07/10/17 (Provi:lEts Signature) DocuSign Envelope ID: 5D25D6E0-7168-4244-AEA3-02E6A45FD852 ATTACHMENT "A" Orange County Certifications—FY 2017-18 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: L362l445B9/4/2017 Certified by. ._ Title: Co-Di rector Date: (Provider's Signature) (Community Empowerment Fund) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID: 5D25D6E0-716B-4244-AEA3-02E6A45FD852 A a CERTIFICATE OF LIABILITY INSURANCE 12T/'31/201'6 THIS CERTIFICATEIS 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 have ADDITIONAL INSURED provisions or 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: BB&T INSURANCE SER`JICES INC/PHS ,a°No,Ext): (866) 467-8730 (AC.00I: (888) 443-6112 272545 P: (866) 467-8730 F: (888) 443-6112 AoR'ESS: PO BOX 29611 INSURER(S)AFFORDING COVERAGE NAICA CHARLOTTE NC 28229 INSURER A: Sentinel Ins Co LTD INSURED INSURER B: INSURER C: COMMUNITY EMPOWERMENT FUND INSURER D. 208 N COLUMBIA ST STE 100 INSURER E. CHAPEL HILL NC 27514 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. ISR TYPE OF INSI724NCE I ADDL SUBR POLICY-,NUMBER I POLICY EFF POLICY EAP LIMITS IIVSR NTT OfM14/DIWYYip IMM/I>D/r1TY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 12, 000, 000 CI-AIMS-MADE X OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) $1-r 000, 000 A X General Liab 22 SBN EN9653 01/26/2017 01/26/2013 MEDEXP(Anyoneperson) $10, 000 PERSONAL&ADV INJURY ,2, 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE ,4, 000, 000 POLICY I JE G- OTHER: I n LOC PRODUCTS-COMP/OP AGG $4, 000, 000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT r,2 0 0 0 0 0 0 I (Ea accident) r r ANY AUTO BODILY INJURY.(Per pe,sen) OWNED SCHEDULED AUTOS ONLY IAUTOS 22 SBN_I EN9653 01/26/2017 01/26/2013 BODILY INJURY(Per accident)$ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE $ DE RETENTION$ WORKERS COMPENSATION PER OTH- 4V)&LILOVERS'LL4AUJTY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEYIN E.L.EACH ACCIDENT 's OFFICER/MEMBER EXCLUDED? (Mandatory in NH) I i wA E.L.DISEASE-EA EMPLOYEE If yes.describe under E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHIG(IRSORD 101,Additional Remarks Schedule,may be attached if more space is required) Those usual to the insured's Operations. I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE Orange County DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 AUTHORIZED REPRESENTATIVE 200 S CAMERON ST HILLSBOROUGH, NC 27278 ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD