HomeMy WebLinkAbout2017-483-E Finance - Orange County Living Wage - Outside Agency Performance Agreement DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
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 Orange County Living Wage, a not-for-profit
corporation, located at 218 Lake Manor Road, Chapel Hill,NC 0 ("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 Orange County Living Wage 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 17725
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 4431.25. 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.
(Orange County Living Wage)
Orange County Outside Agency Performance Agreement
Revised 7/2017 Page 1 of 7
DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
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.
(Orange County Living Wage)
Orange County Outside Agency Performance Agreement Page 2 of 10
Rev. 7/17
DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
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.
(Orange County Living Wage)
Orange County Outside Agency Performance Agreement Page 3 of 10
Rev. 7/17
DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
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 Orange County Living Wage
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:
(Orange County Living Wage)
Orange County Outside Agency Performance Agreement Page 4 of 10
Rev. 7/17
DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
County: Finance &Administrative Services Provider: Orange County Living Wage
Orange County 218 Lake Manor Road
Post Office Box 8181 Chapel Hill,NC 0
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 avi direNilf of the Provider
S.Mak, roiketitAt 8/31/2017
B269B802BO24450...
Date
(Orange County Living Wage)
Orange County Outside Agency Performance Agreement Page 5 of 10
Rev. 7/17
DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
For a �llfoof Orange County Government
L7oL&uut. A-a)mok (S� 9/5/2017
06379949755E477...
Bonnie Hammersley, County Manager Date
(Orange County Living Wage)
Orange County Outside Agency Performance Agreement Page 6 of 10
Rev. 7/17
DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
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
1 ISSI1 ill 61
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117 : hI rib4'11J1 i i 44� II is
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\44° 110111111111111
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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 tol n Submossol alas re IIII . e
March - May Application Review & Agency Presentations
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EXHIBIT A
PROVIDER'S OUTSIDE AGENCY APPLICATION
June Agency Funding Approval by Board/Council
July Contracts Executed & Programs Begin
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.
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EXHIBIT A
PROVIDER'S OUTSIDE AGENCY APPLICATION
➢ 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.
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
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 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
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EXHIBIT A
PROVIDER'S OUTSIDE AGENCY APPLICATION
ecolemenorengecountync.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.
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EXHIBIT A
PROVIDER'S OUTSIDE AGENCY APPLICATION
FOR OFFICE USE ONLY
Agency Orange County Living Wage Received By
Program(s) Certification Program Date/Time /
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Section Subsection
a. ❑Applicant Contact Information
1. Cover Page
b. ❑ Funding Requests
c. ❑ Signed Application Cover Page
d. ❑Signed Disclosure of Conflicts of Interest and Clause
e.
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
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EXHIBIT A
PROVIDER'S OUTSIDE AGENCY APPLICATION
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
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EXHIBIT A
PROVIDER'S OUTSIDE AGENCY APPLICATION
1. COVER PAGE
a) Applicant Contact Information
Applicant Organization's Legal Name: Orange County Living Wage
Applicant Organization's Physical Address: 218 Lake Manor Rd., Chapel Hill, NC 27516
Applicant Organization's Mailing Address: PO Box 1502, Carrboro, NC 27510
Applicant Organization's Web Address: www.orangecountylivingwage.org
Executive Director: Susan Romaine
Telephone Number: 919-619-3408 E-Mail: susanAorangecountylivingwage.org
Tax ID Number:
b) Funding Request
List all FYI 7-18 Human Services (HS) Funding Being Requested —
For All Programs) and the Proposed Use of Funds (2-3 lines or less)
Program Carrbor Chapel Orange Total
o HS Hill - HS County:
HS
OCLW Certification Efforts
Operational Support—This money will support the salary $10,000 $10,000
of a part time administrative assistant(10 hours/week at
$20/hour).
Hosting Fees—This money will cover hosting fees to $1,000 $1,000
support the OCLW website, email service, and mobile
application.
Social Media—This money will cover the expenses of a $2,000 $2,000
social media contractor who will handle content and
platform management for OCLW.
Website—This money will cover the expense of $3,000 $3,000
maintenance and some content redesign of the OCLW
website,
I Mobile Application—This money will cover the $2,000 $2,000
maintenance costs of OCLW's newly developed mobile
application.
Accounting Services—This money will cover the costs of $2,000
$2,000
preparing tax returns, payroll services,and other
assistance.
Totals $20,000 $20,000
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EXHIBIT A
PROVIDER'S OUTSIDE AGENCY APPLICATION
c) To the best of my knowledge and belief all information and data in this application is true
and current. The document has been duly authorized by the governing board of the
applicant.
Signature: / L — - I -Y.--
Executive Director Date
/
0
Signature: / 4
ieoard Chairpdrson Date
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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
YES a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel
Hill, or Orange County?
YES 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?
NO c) Current beneficiaries of the program for which funds are being requested?
NO 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.
Mark Marcoplos is an Orange County Commissioner and as such is a salaried employee of Orange
County.
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.
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EXHIBIT A
PROVIDER'S OUTSIDE AGENCY APPLICATION
Signature: , t(/21, c%e":'*2_
Executive Director Date
Signature: e.
-3 () - (7
Board Chairperson Date
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EXHIBIT A
PROVIDER'S OUTSIDE AGENCY APPLICATION
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):
The first meeting of our steering committee was May 2, 2015. The organization was
incorporated on July 30, 2015. So, the organization has been officially in operation for
about 18 months. Thus far our efforts have resulted in 109 employers in Orange
County certified as paying a living wage. And in order to qualify for certification
employers have increased annual wages by $564,477.
b) Agency's Purpose/Mission (no more than a few sentences):
Orange County Living Wage is a 501(c)3 non-profit organization that promotes a living
wage in Orange County, NC. Through our employer certification program, we certify
Orange County employers that pay their employers a living wage (defined for 2017 as
$13.15/hour without employer-provided health insurance and $11.65/hour with
employer-provided health benefits). The certification is voluntary on the part of the
employers. Our goals are to:
• Reward and recognize employers based in Orange County who pay their workers a
living wage.
• Provide employers with incentives to pay a living wage.
• Connect consumers to employers that provide a living wage and encourage them to
become customers, patients, and clients of those businesses and organizations.
c) Types of Services the Agency Provides (bullet format):
• Certification team members meet with business owners who wish to apply for
certification; an application is completed then, or can be submitted online through our
website.
• The certification team reviews criteria to determine if certification criteria has been
met.
• If the employer meets the criteria, the employer is certified and receives a packet of
materials including a formal letter of acceptance, a framed certificate, a printed decal
to be displayed on the storefront, and a poster for hanging in the workplace.
• An employer can advertise the fact that they are a certified living wage employer and
can use our name and logo in those materials. We display and promote certified
employers on our website, via multiple social media outlets, videos, and news
publications, in a printed brochure, and in a soon to be launched mobile application.
• We also engage in periodic outreach efforts and events to inform the public about
living wage employers in the county. These include regular appearances and
announcements on WCHL and Chapelboro, publicity on WCOM and WHUP and
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newspaper articles. We also have BUYcott events encouraging local residents to
patronize one of our living wage employers on a designated day each quarter.
d) Agency's History with Providing These Services:
Certification of employers has been operational since Summer 2015. All certification
activities are completed solely by a team of seven volunteers. From the beginning
our efforts have been modeled on the certification program in Asheville, NC called
Just Economics that was founded eight years ago and has now certified over 400
employers.
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?)
We reached the #100 mark for certified living wage employers in January 2017. Led
by Orange County, all municipalities and other public employers in the county are
now on board: the Towns of Carrboro, Chapel Hill, and Hillsborough; both public
school systems, OWASA, and Orange County ABC. The other certified employers
include a diverse mix of for-profit and nonprofit businesses and organizations. To
handle the growing workload, Orange County Living Wage hired a part-time
administrative assistant in Fall 2016 to assist with budget management, community
outreach, and fundraising. The administrative assistant position is funded through a
generous outside funding grant from Orange County. Fueling further growth in the
coming year is the development of a social media presence in several outlets,
website development and enhancements, and a new mobile application. All of these
efforts require paid consulting services for both development and ongoing
maintenance.
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.
• 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: 0
# of FTE - Paid Part-Time Positions: .25
# of Volunteers: 11 # of FTE - Volunteers: 1.75 (note: FTE for two
of the volunteer officers is .40)
g) Living Wage
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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.
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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
*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
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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
iii. Does your agency budget show a Surplus or Deficit? A small surplus for FY 2016
and a balanced budget for FY 2017 and FY2018.
Is there a significant change? No
Provide a brief explanation for Surplus or Deficit, and significant changes. N/A
iv. What is your agency's fiscal year? OCLW adopted the calendar year (January 1 —
December 31) for its fiscal year. However, all of the numbers reported in budgets
for the purposes of this grant application have been converted to the county's fiscal
year (July 1 — June 30).
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3. PROGRAM INFORMATION (Submit a separate Section 3 for each program)
Program Name: Orange County Living Wage Certification Program
Program Primary Contact and Title: Susan Romaine, Chair of Steering Committee and
Executive Director
Telephone Number: 919-619-3408 E-Mail: susan(corangecountylivingwage.orq
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
Affordable Healthcare
Education
Family Resources
Jobs/Jobs Training
Food
Transportation
Other: Please specify X
Living Wage 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.
• The 109 businesses and organizations that were certified through January 2017:
We publicize these businesses that pay a living wage and in turn ask them to display
their certification decal and comment on their certification via social media and other
avenues.
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• Chapel Hill-Carrboro Chamber of Commerce: The Chamber shared information from
their surveys of member businesses. The Chamber also promoted our living wage
certification program while hosting a conference with other Chambers from all over
the state. We will continue to engage with the Chamber to inform their members
about our organization and explore ways to collaborate.
• Hillsborough Chamber of Commerce: We will be partnering with this agency in the
same manner as indicated above.
• Just Economics in Asheville, NC: We have consulted with them about the mechanics
of setting up our living wage certification program, and about issues that arise from
time to time about criteria for certification and recertification.
• Durham Living Wage: We have consulted with them about initial steps in launching
a living wage certification program here in Orange County, and website
development.
• Inter-Faith Council for Social Service: The IFC has helped us to reach out to faith-
based organizations to promote our program and the value of certification.
• United for a Fair Economy: We have joined this broad coalition of organizations
seeking to raise the state minimum wage, which has been a stagnant $7.25/hour
since 2009.
• UNC Computer Science Department: As a class project, students worked in
conjunction with faculty to develop (free of charge) a mobile app for living wage
employers. The mobile app is valued at $12,000.
• Cooperative Initiatives of the Carolinas Credit Union League: The director, Jeff
Hardin, produced (free of charge) 25 short videos and screenshots of living wage
employers to be posted on social media. The videos and screen shots are valued at
$3,750.
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?
A member of the certification team meets with each business owner who wishes to
apply for certification. An application is completed at this meeting or can be
submitted to our website in advance of the meeting. The certification team
determines whether our criteria for certification are met. For 2017, the minimum
living wage required for certification is $13.15/hour. If at least fifty percent of an
employee's health insurance premium is paid by the employer, the threshold for
certification is $11.65/hour. If a business's eligibility depends on employees' tips,
commissions or other payments that vary, a member of the certification team
interviews a sample of employees or reviews credit card or other financial records to
verify earnings. If the criteria are met, the business/organization is certified and
receives materials including a decal that can be displayed at the work site indicating
certification. Other materials include a framed certificate, a poster describing the
program to be displayed in the workplace, and a car magnet to publicize the
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program. Our website provides an anonymous avenue for employees to inform our
certification team if they question whether their wages meet our criteria. Once
certified, owners can advertise their certified status through their promotions on
social media, websites, print and broadcast journalism, and other outreach efforts.
Orange County Living Wage displays businesses and organizations that have
become certified on our website and in our social media communications, in a soon
to be launched mobile application, and through our monthly newsletters and
brochures. We engage in periodic outreach promotions to make the public aware of
local businesses that have been certified, the work of our organization, and the
importance of a living wage for all employees. For example, in 2016 we held
BUYcotts at Vimala's Curryblossom Café and Mystery Brewing in which we
encouraged the public to patronize these certified businesses on a designated day.
The work of Orange County Living Wage addresses Orange County's emphasis on
affordable housing, as described in the Consolidated Plan for 2015-2020. The widely
accepted Universal Living Wage Formula used to determine OCLW's living wage is
based on the U.S. Labor Department's policy that employees should pay no more
than 30% of their income toward rent. (That frees up the other 70% of income for
such basic necessities as food, transportation, clothing, child care, and medical
care.) Increasing wages of employees expands the housing options they can afford
for themselves and their families. Increased wages are likely to enable some
employees to spend their housing funds within Orange County rather than having to
go outside the county to secure affordable housing.
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 riorities,
Town of Chapel Hill 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.
Nearly 40% of workers in Orange County earn less than a living wage. If these
workers' wages were brought up to the Orange County Living Wage standard, many
would be lifted out of poverty. Not only would these individuals be better able to
provide for themselves, their children, and other dependents, the overall economy in
the county would benefit substantially. Research has shown that low wage
employees don't have the luxury of saving the additional cash in their pocket from a
pay raise. They spend it on such things as a much-needed haircut, the repair of a
leaking faucet or a flat tire, a winter coat, or the opportunity to put a few extra dollars
into the collection plate at church. Every dollar going into the pockets of low wage
employees adds $1.21 to the local economy.
In addition, a substantial number of local employees cannot afford to live in Orange
County and have to commute from neighboring areas where housing is more
affordable. A recent Chamber of Commerce survey revealed that 41% of
employees in the county commute from outside locations. Only 22% of employees
of the Town of Chapel Hill live in Chapel Hill/Carrboro zip codes. Only 46% of
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Chapel Hill-Carrboro school employees live in the city. Of UNC-Chapel Hill
employees, 49% live in the county, and only 18% of UNC Health Care employees
live in Chapel Hill zip codes. If the wages of some of these workers are raised so
that their employers can become certified by Orange County Living Wage, more will
be able to afford housing in the county and thereby funnel more of their pay checks
into the local economy.
f) Who is your target population of individuals to benefit from this program and how will
they be identified and connected with the program?
County employers who pay their employees a living wage will benefit from being
publicly recognized. Hopefully, this publicity will encourage employers who do not
meet our criteria to re-examine their business plans and work out a way to raise their
wages.
Employees of certified businesses will benefit, particularly if the employer raised
wages in order to qualify for certification. Through January 2017, Orange County
Living Wage had certified 109 employers with a total of 6,966 employees. Of these
employees, 317 received pay raises so that the employer would qualify for
certification. The combined annual pay raise for these 317 employees (all at the
lower end of the pay scale) is $564,477, which amounts to an average $1,780 pay
hike per employee. A notable example of an employer raising wages in order to
qualify for certification is Carol Woods Retirement Community. The organization
raised the wages of 58 of its total 335 employees by a combined $220,000 annually
in order to become a Certified Orange County Living Wage employer. We are also
anticipating a major pay hike by Chapel Hill-Carrboro City Schools in coming months
in order to continue to meet our 2017 threshold of $13.15/hour for all full-time and
part-time employees.
Since employers have gone on public record as supporting a living wage, the wage
structure for all of their employees is likely to be more secure. When wages are
raised for employees who are under the threshold, some employees who are already
over the threshold are likely to receive raises as the wage structure is revamped. Our
organization is particularly concerned about employees who do not make a living
wage. We will continue to reach out specifically to businesses in industries known for
low wages, such as restaurants, child care, elder care, home health, housekeeping
services, and retail.
g) Describe the credentials of the program manager and other key staff. (Ex. Identify
Program Manager and credentials, describe training provided to volunteers, etc.)
Kimberly Brewer has been a resident of Chapel Hill since 1982. She is an Associate Director
at Tetra Tech, an international environmental engineering consulting firm, where she has
been a project manager since 1996. For eight years, she served as the Director of Resource
Conservation and Project Manager for Triangle J Council of Governments, in addition to its
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Interim Executive Director. Ms. Brewer has served the community on a number of boards
and committees including the Orange County Living Wage Steering Committee, Town of
Chapel Hill Planning Board, Chapel Hill Storm Water Advisory Board, Comprehensive Plan
Steering Committee, Triangle Land Conservancy Stewardship Committee, and the CROP
Walk Steering Committee.
h) Describe the specific period over which the activities will be carried out and include
an implementation timeline.
The certification activities are carried out continuously throughout the year by the
volunteer team. The frequency of contact with employers by certification team
members is roughly 8-10 per week. Approximately two employers per week become
certified.
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 Living Wage is a grassroots organization that is focused on
providing benefits to employers and employees alike. Our main goal is to raise
wages to benefit Orange County employees working at the low end of the pay scale
and we promote the many benefits accruing to businesses that pay a living
wage. Many of our certified business owners report improved customer relations
and productivity along with lower rates of turnover and absenteeism. [See
testimonials on our website.] These benefits more than offset the higher costs
associated with the living wage. The local economy also gets a boost. Standard
multiplier models show that for every additional dollar that goes into the pocket of
low-wage workers, an additional $1.21 is pumped into the local economy. Our
efforts serve as a spark plug for the multiplier effect by connecting consumers to
employers that provide a living wage and encouraging them to become customers,
patients, and clients of those businesses and organizations. Instead of objecting to
or protesting the state of the minimum wage here in North Carolina, we take positive
action by emphasizing the benefits of paying a living wage and actively promoting
employers who do so.
j) Describe what would happen if requested funding is not awarded at all or if a reduced
allocation is recommended.
If the funding were not awarded at all, we would not be able to continue employment
for our part-time assistant. More of the certification team's time would then be
devoted to operational and business related tasks, and less of its time would be
focused on outreach to Orange County businesses to encourage and facilitate
certification. The reallocation of time would significantly reduce our daily business
contacts and undermine our ambitious strategic organizational goals. The social
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media and other mechanisms we plan to develop that go a long way toward
promoting living wages in the County, and the benefits to employees and to our local
economy may not be possible. If a reduced allocation of funding is made, we would
have to reduce our services proportionate to the percent of our request that is
granted.
k) Include any other pertinent information.
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Additional Program Information
I) Target Population. An estimate of the total number of employees working for our 109
certified living wage employers is provided. We are unavailable to provide a
breakdown of these employees' demographics at this time.
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
Female
Total 6510 7200 7800
Ethnicity
African-American
American Indian or Alaska Native
Asian
Caucasian
Native Hawaiian or other Pacific Islander
Other: specify
Total 6510 7200 7800
Of the above, how many Hispanic/Latino
Of the above, how many non-Hispanic/Latino
Total 6510 7200 7800
Age
0-5 years
6-18 years
19-50 years
51+ years
Total 6510 7200 7800
Geographic Location
Alamance County
Chatham County
Durham County
Wake County
Orange County Breakdown
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Chapel Hill Public Housing
Town of Chapel Hill (Non-Public Housing)
Town of Carrboro
Town of Hillsborough
City of Mebane(Orange County)
Orange County(Outside Municipalities)
Total 6510 7200 7800
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 Orange County Living Wage
1. Program Activity Name Certifications
Program Goal Grow the number of living wage employers in Orange County to 200
Performance Measures Certifications noted in OCLW database,website, brochures, etc.
Previous Year Program Results 70 living wage employers
Current Year Estimated 135 employers
Results
Next Year Projected Results 200 living wage employers
2. Program Activity Name Social Media
Program Goal Raise OCLW's Social Media Outlets to 4
Performance Measures Facebook, Instagram,Twitter,YouTube in production
Previous Year Program Results 1 outlet utilized (Facebook)
Current Year Estimated 2 outlets utilized (Facebook, Instagram)
Results
Next Year Projected Results All 4 outlets utilized
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3. Program Activity Name Newsletter
Program Goal Electronic newsletter to entire listsery on a monthly basis
Performance Measures Track electronic newsletters
Previous Year Program Results 0 newsletters
Current Year Estimated 7 newsletters
Results
Next Year Projected Results 12 monthly newsletters
4. Program Activity Name BUYcotts
Program Goal Organize quarterly BUYcotts on behalf of living wage employers
Performance Measures Track Number of BUYcotts
Previous Year Program Results 1 (Vimala's Curryblossom Café)
Current Year Estimated 3 (Mystery Brewing, Greenbridge Condominiums for benefit concert,
Results plus one more)
Next Year Projected Results 4 BUYcotts
Program Activity Name Raise Wages
Program Goal Increase number of living wage employers raising wages to qualify for
certification to 25
Performance Measures Applications from and conversations with living wage employers and
sometimes employees(when tipped)
Previous Year Program Results 9 out of the total 70 living wage employers lifted wages to qualify
Current Year Estimated 17 out of the total 135 living wage employers lift wages to qualify
Results
Next Year Projected Results 25 out of the total 200 living wage employers lift wages to qualify
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n) Program Budget—OCLW's program budget is the same as its agency 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.
3. This program budget represents what percent of the agency budget? 100 %
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.
Here, the "individual" refers to our living wage employer. As OCLW's number of certified employers
grows, so too does the cost of the publicity for sharing their names with the community.
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Actual 2015-16 Estimated 2016-17 Projected 2017-18
Total Cost of Program $6,872 $26,250 30,000
Total # of Individuals 70 135 200
Cost Per Individual $98.00 $194.00 $150.00
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Agency Budget
Operating Budget for Entire Agency
AGENCY NAME: Orange County Living Wage
Actual Estimated Projected Percent
AGENCY REVENUE 2015-16 2016-17 2017-18 Change
Private Donations $ 5,300 $ 6,000 $ 6,000 0%
Agency Generated Revenue (fees) $ - $ - $ - 0
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 $ - $ 16,750 $ 20,000 19%
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 $ 3,000.00 $ 3,500.00 $ 4,000.00 $ 0.14
Other Revenue 0
Total Agency Revenue $ 8,300 $ 26,250 $ 30,000 14%
AGENCY EXPENSES
Compensation $ 1,290 $ 4,000 $ 10,000 150%
Rent& Utilities $ - $ - $ - 0
Supplies & Equipment $ 3,392 $ 4,600 $ 7,000 52%
Travel & Training $ - $ - $ - 0
Other Expenses: $ 2,190 $ 17,650 $ 13,000 -26%
Total Agency Expenses $ 6,872 $ 26,250 $ 30,000 14%
SURPLUS/(DEFICIT) FOR PERIOD: $ 1,428 I $ - I $ - I 0
FY 2015-16 Comparative Agency Budget
Revised 9/29/2014
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Program Budget
Operating Budget for Program
PROGRAM NAME Orange County Living Wage
Actual Estimated Projected Percent
PROGRAM REVENUE 2015-16 2016-17 2017-18 Change
Private Donations $ 4,693 $ 18,000 $ 4,000 -78%
Program Generated Revenue $ - $ - $ - 0
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 $ - $ - $ - 0
Other-Orange County $ - $ 16,750 $ 20,000 19%
Other-Town of Hillsborough $ - $ - $ - 0
Other Government Grants
Triangle United Way $ - $ - $ - 0
State Government $ - $ - $ - 0
Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0
Private Foundation Grants $ 6,500.00 $ 7,000.00 $ 0.08
Other Revenue $ 2,600 $ 3,000 $ 0.15
Total Program Revenue $ 4,693 $ 43,850 $ 34,000 -22%
PROGRAM EXPENSES
Compensation $ 510 $ 6,000 $ 6,000 0%
Rent& Utilities $ - $ - $ - 0
Supplies & Equipment $ 466 $ 2,500 $ 2,500 0%
Travel &Training $ - $ - $ - 0
Other Expenses: $ 1,578 $ 11,500 $ 14,000 22%
Total Program Expenses $ 2,554 $ 20,000 $ 22,500 13%
SURPLUS/(DEFICIT) FOR PERIOD: $ 2,139 I $ 23,850 I $ 11,500 I -52%
DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
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.
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DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
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 webpaqe 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.
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DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
EXHIBIT A
PROVIDER'S OUTSIDE AGENCY APPLICATION
Home
Email address Home Phone Mobile address Affiliation
1605 Nature
Fountain Conservancy
Mike Ridge Road,
Andrews mikeandrewsnc(c�amail.c Chapel Hill,
(Treasurer) om 919-949-6936 NC 27517
1510 Livia Physical
Susan Drive, Therapist
Attermeier Hillsborough,
(Secretary) satter(a�bellsouth.net 919-929-9533 919-414-3932 NC 27278
1602 Retired, Duke
Claymore University
Road,
Chapel Hill,
John Barrow lohnbarrow(c�nc.rr.com 919-818-0226 NC 27516
301 Purefoy TetraTech
Kimberly Road,
Brewer(Vice kimberly(c�oranciecountyli Chapel Hill,
Chair) vinawaae.orq 919-968-4251 919-357-2122 NC 27514
Retired, Cecil G.
Sheps Center
910 Emory for Health
Drive, Services
Victoria Chapel Hill Research, UNC-
Freeman freevictoria ,gmail.com 919-942-0669 919-636-8765 NC 27517 Chapel Hill
165 Retired,
Viburnum Research &
Way, Evaluation
steve @orangecountylivin Carrboro, NC Associates
Steve Jenks gwage.org 919-942-9452 27510
6329 U.S. Department
Cardinaux of Agriculture
Lane, Holly
Springs, NC
Chris Lathrop chris @lathrop.com (910)551-9378 27540
7207 Marcoplos
Southern Construction
Trail, Chapel
Mark Hill, NC
Marcoplos marcoplos(c.bellsouth.net 919-524-6287 27516
218 Lake N/A
Susan Manor Road,
Romaine susan(c�orangecountylivin Chapel Hill,
(Chair) gwage.orq 919-619-3408 NC 27516
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.
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DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
EXHIBIT"B"
Scope of Services—FY 2017-18
Outside Agency Performance Agreement
Agency Name: Orange County Living Wage
Program Name: Living Wage Employer Certification Program
Funding Award: $17,725
Outline how the agency will spend Orange County's funding award.
Expense Description Amount
Operation support/salary(paid certification outreach and certification-related follow up) 9,725
Hosting fees and website development 4,000
Social media/marketing - 2,000
Accounting 2,000
Program Services
Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018.
• Contact employers in the business, non-profit, and public sectors to engage them in a discussion
about benefits to them as living wage employers
• Certify employers and promote them to the community as living wage employers
• Target businesses with higher percentages of low-wage workers and develop strategy to better
enable them to certify
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
Contact employers for living wage certification 300
Certify employers for paying a living wage 75
Re-certify 85%of all employers due for re-certification through June 2018(64 total) 54
Certify 10 businesses with low-wage workers(included in 75 new employers in FY2017-2018) 10
DocuSigned by:
S(tStU,t rboutth,t, Executive Di rector 8/31/2017
--- :26 802B024450...
Certified by: 44.A._ �' , - Title:t-X-tx Pe r'ec f t' Date: 7- 2
(Provider's Signature)
DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
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:
S.Me& rokait t 8/31/2017
Certified by: Title: Executive Di rector Date:
y• a2ssaRmamal5a_
(Provider's Signature)
(Orange County Living Wage)
Orange County Outside Agency Performance Agreement Page 10 of 10
Rev. 7/17
DocuSign Envelope ID:ODO4B5DD-363F-41 FF-BD24-FAD291133B51
•
ORANGE COUNTY LIVING WAGE
pK;H, Y PP,CAPt
WINIV OliANGE.001 IN I ill VI NCON1GF(MG
January 28, 2017
Dear Orange County Commissioners,
We have reviewed the liability insurance requirement in Orange County's Outside
Agency FY2017-18 funding application and believe Orange County Living Wage to be
exempt from the liability insurance requirement.
Please feel free to contact us if you have any questions.
Sincerely,
/9-
Susan Romaine
Executive Director, Orange County Living Wage
919.619.3408
sus n@ol ngeco n tyl ivi ng wage„o rg
—
Annie Sullivan
Law Firm of Annie L. Sullivan
919.636.1687
alb'la w 0)1)c Us u ad