Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
2017-481-E Finance - Dispute Settlement Center, Inc. - Outside Agency Performance Agreement
DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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 Dispute Settlement Center, Inc., a not-for-profit corporation, located at 302 Weaver Street, Carrboro,NC 27510 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Dispute Settlement Center, Inc. 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 81500 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 20375. 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. (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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. (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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. (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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 Dispute Settlement Center, Inc. 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: (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC County: Finance &Administrative Services Provider: Dispute Settlement Center, Inc. Orange County 302 Weaver Street Post Office Box 8181 Carrboro,NC 27510 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable,it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. 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.r ro ta of the Provider MAW htn,btt-rSbtt, 8/31/2017 35CO2A482G124C8... Date (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC For 4Q924gdakwlf of Orange County Government 701AAIt,tf, kuminkU"SLUI 9/5/2017 063799eg-55E477... Bonnie Hammersley, County Manager Date (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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 ie /47,72'---- -r-'\r0_,,.,h,, iiiilloii II I, ilfrhilli, I, Illoir 4, I 1016 1111111111111H lei 1 1111 I oil 11111111111 IIHH1111111,11111111,111 Nip iJr Ni N II, II 1 Iniongaj •i, � G keit 'I iu� r � I 1} �' t ���� � Ili oh 4 \ 1� III�DIlnllli cy itr II "k$ 11111111 1111 1S$0 11 111111111 1111111111 A DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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 nu ry A IIIIII IIIurc ul n Submossol alas re IIII ue March - May Application Review & Agency Presentations June Agency Funding Approval by Board/Council July Contracts Executed & Programs Begin DO NOT SUBMIT THIS PAGE 2/8/2017 11:26:12 AM ll' age 2 r 2 2 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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 ervice Town arr oro 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( 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 2/8/2017 11:26:12 AM II I:' 3 3 .t 2 2 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Human ervice Town a el 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 jthompson( 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 ervice 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 2/8/2017 11:26:12 AM II I:' 1 .t 2 2 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency Dispute Settlement Center Received By Program(s) Mediation Date/Time / I RRRrRRRRRREFFEEFFERRr RRRREFFERRRRRRRRRRfiRRRRRRRRREFFERRRRRr7RRRRRRRRRRRRRRREFFE RRRRRRRRRRRRRREFFEfiRRRRRRRRRRRRRRRRRRRRr7REFFERRRE Section Subsection 1. Cover Page a. x❑ Applicant Contact Information b. x❑ Funding Requests c. x❑ Signed Application Cover Page d. x❑Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. x❑ Agency's Years in operation b. x❑ Agency's Purpose/Mission c. x❑ Agency's Types of Services Provided d. x❑ Agency's Experience with Programs e. x❑ Other Pertinent Agency Information f. x❑ Schedule of Positions g. x❑ Living Wage h. x❑ Agency Budget 3. Program Information a. x1=1 Human Services Needs Priority b. x❑ Type of Program A separate Section 3 is c. x❑ Agency Collaboration required for each program. d. x❑ Summary of Program e. x❑ Description of Identified Need f. x❑ Description of Population to be Served g. x❑ Program Staffing, Capacity, & Expertise h. x❑ Program Implementation Timeline i. x❑ Value of Investment j. x❑ Impact of Reduced/No Allocation k. x❑ Other Pertinent Information I. x❑ Target Population/Beneficiary Chart m. x❑ Work Statement n. x❑ Program Budget, Detail, & Cost per Individual 4. Attachments a. x❑ 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. x❑ IRS Federal Form 990 c. x❑ NC Solicitation License d. x❑ IRS Federal Tax-Exemption Letter e. x❑ Certificate of Insurance f. x❑ List of Board of Directors g. x❑ Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 2/8/2017 11:26:12 AM Page 5 r 2 2 DocuSign Envelope ID:88AE E9B F-924A-442D-B D41-DC640F1E 1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact information Applicant Organization's Legal Name: Dispute Settlement Center, Inc. Applicant Organization's Physical ddress: 302 Weaver Street, Carrboro, NC 27510 Applicant Organization's Mailing Address: same Applicant Organization's Web Ad ress: www.disputesettlement.org Executive Director: Frances Henderson Telephone Number: (919) 929-8800 E-Mail: fenderson Odisputesettlement.orq Tax ID Number: b) Funding Request List all FYI7-18 Human Services (HS) Funding Being Requested — For All Programs) and the Prop sed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total HS Hill-HS .County-HS Conflict Resolution trainings and Restorathke Justice $10,000 ' $15,000 $25,000 for Youth-in the community and with tuve ile court, " referrals and their•families. 1°_ ` ° .." Mediation—Helping settle interpersonal didputes $83,000 $83,000 referred from Orange County Criminal District Court; helping separating couples with disagreem nts over parenting, finances, and other issues;facilitating conversations between Medicaid recipients and the state over services Totals $10,000 $15,000 $83,000 $108,000 c) To the best of my knowledge and belief all information and data in this application is true and current. The documen has been duly authorized by the governing board of the applicant. Signature: -•-' ' . OF 2�" /7 Executive Director Date Signature: / /�c C Board airperson Date AGENCY INFORMATION 1/18/2017 12.07:30 PM Page 6 of 19 DocuSign Envelope ID:88AE E9B F-924A-442D-B D41-DC640F1E 1 BAC EXHIBIT A PROVIDERS OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL C NFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or emp oyees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ EJ a) Employees of or closely related to employees of the Town of Carrboro, the Town of / Chapel Hill, or Orange Count?? ❑ [ 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? E ,c) Current beneficiaries of the program for which funds are being requested? ❑ p 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. 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 activi ies 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, s 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 I ith 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: •- A-C.e.4A- 1 t--2- ��f 7 ecutive Director Date Signature: i / 4e /0 Boa d air erson Date AGENCY INFORMATION 1/18/2017 12:07:30 PM Page 8 of 19 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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): September 28, 1978 b) Agency's Purpose/Mission (no more than a few sentences): "To promote and bring about the peaceful settlement of disputes and prevent the escalation of conflict through mediation, conciliation, facilitation, and training." c) Types of Services the Agency Provides (bullet format): o Mediation for court-referred and community-referred interpersonal disputes including family, business, neighborhood, Medicaid Appeals, and eldercare; o Training for adults in conflict resolution, mediation, and facilitation, as well as interventions in disputes; o Facilitation, mediation and consensus-building for groups, organizations, and governmental units; and o Training, mediation and development of Restorative Practices for youth in school, community, and juvenile court settings. d) Agency's History with Providing These Services: We have provided mediation services since 1978, as the founding community mediation center in North Carolina. DSC continues to relieve the Orange County Courts of hundreds of cases each year —those best settled through mediation - thereby freeing up the judges and court staff for other issues. We also offer sliding scale separation and divorce mediation sessions on issues including parenting arrangements, financial divisions, alimony and custody. We have seen an expansion of separation/divorce mediations, with the sliding scale fee basis being very important for people who are underemployed or experiencing job loss. We also help families with eldercare issues and neighbors and small business people with disputes. In 2012 we began assisting Orange County Medicaid recipients with their service provision appeals, by facilitating conversations with providers. In addition (not part of this proposal) we have provided Youth Services since 1984, Public Disputes (facilitation) services since 1986, and have added training and intervention services for individuals and groups. Our youth services have evolved over time to include Restorative Justice (or Restorative Practices.) 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?) Agency staff is stable (average tenure is 17 years.) as is the Board of Directors. New Initiatives: (Related to this Program Application) In recent years we have, in response to requests from the bench, received 50-C cases as appropriate, and Agency Information 2/8/2017 11:26:12 AM II I:' r 2 2 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION cases from Truancy Court. Criminal District Court remains our primary source of referrals. In 2016, we became part of the system for the County's Misdemeanor Diversion Program, which supports certain 16 and 17 year olds being treated as juveniles. This means they receive services as juveniles would, and stay out of Criminal District Court. 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. • 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: 0 # of Volunteers: 37 # of FTE -Volunteers:2 f) 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 We were proud to be on the very first list of certified Living Wage Employers. What we (and others we are sure) really struggle with is helping staff get affordable health care. If no, please explain. Agency Information 2/8/2017 11:26:12 AM Page 9 lr 22 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION g) 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) Human Services funding and JCPC matching funds 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 Restorative Practices and 9,000 $10,000 Carrboro Mediation for Youth Restorative Practices and $14,000 $15,000 Chapel Hill Mediation for Youth Mediation — Court and Family $80,000 $83,000 Orange County Total 103,000 108,000 Restorative Practices and 8118 9000 Orange County JCPC matching Mediation for Youth funds *Add rows or attach additional page, if needed. ii. Submit your agency's 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, 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 Agency Information 2/8/2017 11:26:12 AM Page in J 22 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • 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 iii. Does your agency budget show a Surplus or Deficit? We had a slight deficit in FY16 of 2%. We don't know yet how FY17 will come out. We attempt to maintain several months operating expenses to be able to absorb this. In the overall budget, it is difficult to project the amount of fee for service projects that come our way that we can complete in a fiscal year. Is there a significant change? Yes/No NO Please provide a brief explanation for Surplus or Deficit, and significant changes. This year we used some reserve funds to invest in staff and our infrastructure. At the same time, one of our foundation supporters told us they were moving, and would stepping down the support to us in the next two years, which has been a loss of$5,000 and next year, $10,000. We also no longer have United Way support. This has meant pressure to raise fees for service and also more contributions, which we have been marginally successful with. iv. What is your agency's fiscal year? July 1 — June 30 (Example: July 1, 2016 through June 30, 2017) Agency Information 2/8/2017 11:26:12 AM P '11 • .f 22 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: MEDIATION Program Primary Contact and Title: Frances Henderson, Executive Director Telephone Number: 919 929-8800 ext 11 E-Mail: fhenderson@disputesettlement.org a) Indicate the type of Human Service Needs Priority, if program applicable: x 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 Affordable Healthcare Education Family Resources Jobs/Jobs Training Food Transportation Other: Please specify x Community well-being through conflict resolution x x x x 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. We receive case referrals from these entities, among others: Orange County Criminal District Court; Orange County Civil District Court (50-C cases) Orange County Magistrates; Orange County Small Claims Court; Orange County Animal Control; Orange County Senior Centers; Orange County Clerk of Court; Orange County Department on Aging: PROGRAM INFORMATION 2/8/2017 11:26:12 AM Page 12 • .f 22 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Homeowners' Associations (HOAs): Chapel Hill Police Department Crisis Unit; Orange County DSS; Town of Chapel Hill Ombuds Office; Town of Chapel Hill Human Resources; Town of Carrboro; Chapel Hill- Carrboro City Schools; Orange County Schools; Family law attorneys; Family therapists; NC Office of Administrative Hearings (Medicaid Appeals) Compass Center; Congregations, nonprofits and businesses; Senior Care providers. 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? In Orange County Criminal District Court, the judges and assistant district attorneys refer cases to us and we then screen for appropriateness and voluntariness. An appropriate case involves an interpersonal dispute (leading to, for example, charges of harassment, communicating a threat, injury to personal property, etc.) without domestic violence, in which the parties agree to mediate. Most court clients have very few resources and often need to get back to their jobs. They also need real resolution of the problem between themselves and their neighbor, co-worker, or family member. In the case of family mediation, clients are referred to Dispute Settlement Center through attorneys, therapists, or social services agencies, or self-referred. Our sliding scale fee structure enables people of all income levels to have access to high quality mediation. Medicaid Appeals cases are referred to us through a program through Office of Administrative Hearings. This program serves the very poor and disabled in Orange County who have been denied Medicaid services or support and have appealed the denial. The Orange County Board of County Commissioners' goals include to "Create a Safe Community" and to "Foster a community culture that rejects oppression and inequity." Dispute Settlement Center helps people in conflict work through their differences in safe environments so that they can move on with their lives with less stress and perhaps improved relationships. Through the mediation process, they may learn skills that help them speak up for themselves more effectively. This, we PROGRAM INFORMATION 2/8/2017 11:26:12 AM II I:' I 3 r 2 2 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION believe, is a building block for democracy and inclusiveness. 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 HIII Council Goals, Carrboro goals, 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. "Ending the overuse of jail will reduce economic and racial inequalities and is an essential part of advancing civil rights in the 21st century." Nicholas Turner, President and Director, Vera Institute of Justice. As quoted above on the County's website, the BOCC recognizes that smooth and equitable functioning of the court system is a part of larger goals. Any of the 134,000 Orange County residents may in fact be in Criminal District Court, but many are low- resource individuals working in hourly positions. Court may have been a last resort for them in a conflict with their friend, neighbor, family member or colleague. While they have a right to use court, it may not be the best route to resolution for them. We give them an option of mediation, which can mean a quicker return to work, as well as a much better resolution. We cannot claim to prevent violence or that we advance civil rights. But, contributing to the efficiency of the court system AND helping people take more control over their lives contributes to both of these BOCC goals. As we encourage mediation and conciliation in the community (out of court) we also hope to contribute to the County goals of full civic participation, in a safe community, and promoting the well-being of all citizens. Conflict avoidance (or fighting) is stressful. In the case of family mediation, there is strong research showing that mediation is better for the long-term relationships between parents and children. (see Robert Emery, PhD. At University of Virginia's Center for Children, Families and the Law.) Likewise in eldercare mediation, or other family situations, relationships can be improved, or salvaged, in mediation. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? • Court: Anyone in Criminal District Court as a result of a civilian-generated warrant may be referred to us by the court (we screen for violence) and have an option to mediate. Also, we can receive referrals from Small Claims Court and Truancy Court. • Family cases: Lawyers, therapists, family service providers and others in the community refer people to us. People know of us and self-refer. Senior care providers and the Orange County Clerk of Court may send us eldercare disputes. • Medicaid Recipients: The Office of Administrative Hearings sends these poor and disabled citizens (or their advocates) to us for facilitation of disputes over Medicaid- funded services. PROGRAM INFORMATION 2/8/2017 11:26:12 AM I:' 1 1 • r 2 2 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Our Mediation Coordinator has 22 years mediation experience, and her staff co- mediator has six years mediation experience, a law degree and a Certificate in Dispute Resolution from NC Central School of Law. They oversee staff and volunteer mediators: each has gone through from 24-60+ hours of mediation training, an apprenticeship, and years of experience. The agency's Executive Director is an attorney and is also certified by the NC Dispute Resolution Commission for Mediated Settlement Conferences. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. July 1, 2017 through June 30, 2018 we will attend Criminal District Court "People's Court" sessions regularly for referral, interviewing, and mediation. This means Mondays and Thursdays, with a team of mediators attending on the People's Court days. In addition, we receive referrals, do intake, and mediate family, community and eldercare cases throughout the year. Medicaid Appeals are referred to us when initiated, and we have 25 days in which to hold a mediation and report. 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) Orange County has a role to play in making sure that the local court system functions effectively. A crowded docket strains resources and lack of efficiency in case management could also mean increased crowding and liability in the local jail. Chief District Court Judge Joseph Buckner has said that his courthouse would "be in lock-down" without the assistance of Dispute Settlement Center mediators relieving the courts. In addition, offering disputants a chance to sit down with mediators helps them reach lasting resolutions so that behaviors leading to warrants are less likely to be repeated. These are public safety issues. Families in Orange County need affordable mediation services when faced with separation and divorce. While there are private mediators, we are the only mediators with a sliding scale fee structure. Low to moderate income couples — and those unemployed- need this support. In addition, as the population ages, more families struggle with transitions around care of elders. We offer a different way, beyond fighting, litigation, or suffering in silence. This includes assisting the Orange County Clerk of Court with family situations at his request. Finally, having a place to contact for help and support with neighborhood or other conflicts means we can be a gentler community — where people try to talk to each other over differences, rather than litigating, fighting, or avoiding each other. j) Describe what would happen if requested funding is not awarded at all or if a reduced PROGRAM INFORMATION 2/8/2017 11:26:12 AM II I:' 15 r 2 2 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION allocation is recommended. Without funding, we could not attend Criminal District Court. After the NC Legislature de-funded mediation throughout the state for FY11, Orange County picked up support for this needed service. Note that in FY02, the NC Legislature was providing $84,530 in support for this program. Over time, we have found some general support for mediation. We believe that it can be agreed that court mediation, however, is properly supported by government. k) Include any other pertinent information. We would like to note that mediation is a practice which does not lend itself to easy evaluation. We maintain demographic information on clients and resolution rates, but this does not tell the whole story. In many cases, we talk the parties separately through the conflict, encourage ways of conciliation, and then they may not mediate, or one side refuses. In other cases, there may be a long mediation but no resolution — nonetheless progress has been made. Mediators are trained to not focus on resolutions but on first, doing no harm, and second, empowering the parties to communicate and negotiate for themselves. Of course, resolutions can be great things, and we note that in over 80% of mediations held, there is a resolution. In Criminal District Court, the cases can be very involved and take a few hours of mediation, or be short. Orange County support enables us to give each case the attention that is needed. We are trying to be realistic in setting number goals. It all depends on the number of appropriate cases that are referred to us, and this may vary widely. The agency must maintain trained available personnel no matter how many cases there are. PROGRAM INFORMATION 2/8/2017 11:26:12 AM II I:' 1G r 22 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Proclram 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 334 325 350 Female 481 425 400 Total 815 750 750 Ethnicity African-American 220 210 210 American Indian or Alaska Native Asian Caucasian 562 470 480 Native Hawaiian or other Pacific Islander Other: specify Total 782 690 690 Of the above, how many Hispanic/Latino 33 70 60 Of the above, how many non-Hispanic/Latino 782 680 690 Total 815 750 750 Age 0-5 years 6-18 years 19-50 years 51+ years Total 0 0 0 Geographic Location Alamance County Other 47 Other 26 35 Chatham County Durham County 53 45 45 Wake County 60 30 35 Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non-Public Housing) 276 255 250 Town of Carrboro 54 65 60 Town of Hillsborough 137 120 120 City of Mebane(Orange County) Orange County(Outside Municipalities) 188 209 205 Total 815 750 750 PROGRAM INFORMATION 2/8/2017 11:26:12 AM Page 1 /' • .f 22 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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 MEDIATION (Orange County) 1. Program Activity Name Mediation Program Goal Provide access to mediation for Orange County citizens in Criminal District Court (including Truancy, 50-C cases from Civil Court, Small Claims, and Misdemeanor Diversion Program) and to the community through family mediation and Medicaid Appeals mediation. Performance Measures Numbers of people served and resolution rate in cases mediated. Previous Year Program Results 815 (+80%) Current Year Estimated Results 750 (+80%) Next Year Projected Results 750 (+80%) 2. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 3. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PROGRAM INFORMATION 2/8/2017 11:26:12 AM Page 1 • .f 2 2 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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. "Other" items include printing, publicity, insurance, contractual for website design, fundraising expenses, publications and telecom. 3. This program budget represents what percent of the agency budget? 32 % 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. Actuat 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program 149,948 154,000 158,620 Total # of Individuals 815 750 750 Cost Per Individual $184 $206 $211 PROGRAM INFORMATION 2/8/2017 11:26:12 AM Page 2 0 f 22 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Dispute Settlement Center, Inc. Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 49,685 $ 54,000 $ 56,000 4% Agency Generated Revenue (fees) $ 226,871 $ 223,000 $ 234,000 5% Local Government Grants: Human Services-Town of Carrboro $ 8,000 $ 9,000 $ 10,000 11% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 12,000 $ 14,000 $ 15,000 7% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ 76,000 $ 80,000 $ 83,000 4% Other- Orange County $ 7,481 $ 8,118 $ 8,700 7% Other-Town of Hillsborough $ 2,000 $ - $ - 0 Other Government Grants Triangle United Way $ 3,558.00 $ - $ - 0 State Government $ 25,538.00 $ 27,061.00 $ 29,000.00 $ 0.07 Federal Government (CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 37,500.00 $ 47,500.00 $ 42,500.00 $ 0.11 Other Revenue $ 13 $ 80 $ 50 $ 0.38 Total Agency Revenue $ 448,646 $ 462,759 $ 478,250 3% AGENCY EXPENSES Compensation $ 409,168 $ 419,359 $ 431,526 3% Rent& Utilities $ 10,600 $ 10,375 $ 10,375 0% Supplies & Equipment $ 8,870 $ 7,500 $ 8,000 7% Travel & Training $ 8,263 $ 6,500 $ 6,800 5% Other Expenses: $ 21,169 $ 21,000 $ 21,549 3% Total Agency Expenses $ 458,070 $ 464,734 $ 478,250 3% SURPLUS/(DEFICIT) FOR PERIOD: $ (9,424)1 $ (1,975)1 $ - I 100% FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME MEDIATION Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 20,000 $ 23,000 $ 23,620 3% Program Generated Revenue $ 32,080 $ 31,000 $ 34,000 10% Local Government Grants: Human Services-Town of Carrboro $ - $ - $ - 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 76,000 $ 80,000 $ 83,000 4% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 20,000.00 $ 20,000.00 $ 18,000.00 $ 0.10 Other Revenue $ - $ - $ - 0 Total Program Revenue $ 148,080 $ 154,000 $ 158,620 3% PROGRAM EXPENSES Compensation $ 125,513 $ 129,278 $ 133,170 3% Rent& Utilities $ 2,650 $ 2,700 $ 2,700 0% Supplies & Equipment $ 3,217 $ 3,247 $ 3,400 5% Travel &Training $ 4,131 $ 4,275 $ 4,600 8% Other Expenses: $ 14,437 $ 14,500 $ 14,750 2% Total Program Expenses $ 149,948 $ 154,000 $ 158,620 3% SURPLUS/(DEFICIT) FOR PERIOD: $ (1,868)1 $ - I $ - I 0 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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 Frequently Asked Questions Guide ( F), 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 2/8/2017 11:26:12 AM II I:' 21 J 22 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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 $2 million Aggregate Injury Property $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 2/8/2017 11:26:12 AM II I:' 2 2 .t 2 2 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC EXHIBIT`B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Dispute Settlement Center Program Name: Mediation Funding Award: $81,500 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel costs related to Court and Family mediation,including Mediation Coordinator s and $81,500 administrative support Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Mediation for Orange County citizens in Criminal District Court, Truancy, and 50-C cases from Civil District Court, and Misdeameanor Diversion (MDP) • Family Mediation for Orange County citizens facing separation and divorce and other family conflicts • Mediation of Medicaid Appeals for service denial for poor or disabled Orange County citizens 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 Mediation services for a projected 750 Orange County residents through court,family,and +80% Medicaid mediation services resolution rate for cases mediated IDocuSigned by: VtOS hliLbf VSbln Executive Di rector 8/31/2017 Certified by: 35CO3A4B2C124C8_. Title: Date: (Provider's Signature) DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC 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: l �A�n,Gt S (-k-f,ln,i, VSetn, 8/31/2017 Certified by: 35CO3A4B2C124Ca_, Title: Executive Di rector Date: (Provider's Signature) (Dispute Settlement Center,Inc.) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:88AEE9BF-924A-442D-BD41-DC640F1 E1 BAC ACC30RD® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 6/27/2017 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 Kelley Loso NAME: y Business Insurers of Carolinas (a//C,NNE,Ext): (919)968-4611 FAX No): (919)968-8991 800 Eastowne Drive, Suite 208 AE-MDDAIL PO Box 2536 INSURER(S)AFFORDING COVERAGE NAIC# Chapel Hill NC 27515-2536 INSURERA:Hamilton Mutual Insurance Co 14125 INSURED INSURER B:Employers Mutual Casualty 21415 DISPUTE SETTLEMENT CENTER INC INSURERC: 302 W WEAVER ST STE A INSURER D: INSURER E: CARRBORO NC 27510-6004 INSURER F: COVERAGES CERTIFICATE NUMBER:17/18 WC,Bop 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 W LIMITS LTR INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 A CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 4W54487 6/17/2017 6/17/2018 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: Hired/Borrowed $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? N/A B (Mandatory in NH) 4H54487 6/17/2017 6/17/2018 E.L.DISEASE-EA EMPLOYEE$ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION jethompson @orangecountync. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN PO Box 8181 ACCORDANCE WITH THE POLICY PROVISIONS. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Kelley Loso/KELLL ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(2014011