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2017-499-E Finance - Volunteers for Youth - Outside Agency Performance Agreement
DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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 Volunteers for Youth, a not-for-profit corporation, located at 205 Lloyd Street, Suite 103, 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 Volunteers for Youth agree as follows: 1. Term of the Agreement. The tenn 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 8750 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 2187.5. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Volunteers for Youth) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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. (Volunteers for Youth) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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. (Volunteers for Youth) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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 Volunteers for Youth 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: (Volunteers for Youth) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 County: Finance &Administrative Services Provider: Volunteers for Youth Orange County 205 Lloyd Street, Suite 103 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. For Poribrivitif of the Provider -G' '- I 8/31/2017 43B86356CBFF4E6 , Date (Volunteers for Youth) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 For a �onu dtadf of Orange County Government bU i,lt, t'GUMwte-rStui 9/8/2017 0C37004137'.,E477... Bonnie Hammersley, County Manager Date (Volunteers for Youth) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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 ,fir , AKII��F !! � UI : 1111 �� Ik4 al 1,� si DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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 January 31 is ti Submissions are e 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 10:03:24 AM M:1 i ::I 0 2 2 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION SUBMITTAL INFORMATION Welcome to the Outside Agency Common Funding application for local/general funds, which will be distributed through this competitive application process. All entities or organizations requesting funds must complete and submit this application prior to the deadline to be considered for FY 2017-2018 funding. The Application Submittal Deadline is: Tuesday, January 31, 2017 5:00 PM In the event of inclement weather, check the website for each Town/County you are applying to, for further instructions. Please note that late, handwritten, or incomplete applications will not be accepted. (Applications not signed by the Chair or President of the Board of Directors, are considered incomplete.) An application orientation workshop will tentatively be held on Tuesday, November 29, 2016 at 9 AM to Noon to review the application and submittal requirements. SUBMITTAL REQUIREMENTS FOR EACH MUNICIPALITY Human Services— Town Of Carrboro Applications are accepted once a year and reviewed by the Town's Human Services Advisory Commission, which makes a recommendation for funding to the Board of Aldermen for final approval. For more information about the Town of Carrboro Human Services program, see here. Questions and submittals should be directed to: Annette Stone, 301 W. Main Street Carrboro, NC 27510 919-918-7319 astone @townofcarrboro.org 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 10:03:24 AM „: Ji ::I 0 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Human Services — Town Of Chapel Hill In 1982, the Town established local funding to support local nonprofit organizations that carry out human service work throughout the community. Applications are accepted once a year and reviewed by the Town's Human Services Advisory Board, which makes a recommendation for funding to the Town Council for final approval. For more information about the Town of Chapel Hill Human Services program, see here. Questions and submittals should be directed to: Jackie Thompson 405 Martin Luther King Jr. Blvd. Chapel Hill, NC 27514 919-969-5081 jthompson©townofchapelhill.org Submission: ➢ We strongly encourage applications to be single-spaced, with 12-point arial font and normal margins. ➢ Application: Two (2) paper copies of the application with ORIGINAL signatures must be hand delivered or mailed to Jackie Thompson, 405 Martin Luther King, Jr. Blvd., Chapel Hill, NC 27514; AND ➢ Attachments: The application submittal must be accompanied by a flash drive with the application and all attachment files in electronic format. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. Human Services— Orange County For more information about the Orange County Human Services program, see here. Questions and submittals should be directed to: Allen Coleman PO Box 8181 Hillsborough, NC 27278 (919) 245-2151 acoleman @orangecountync.gov Submission: ➢ Email application and ALL Attachments prior to the deadline. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. Please request a delivery receipt of email with application and attachments. DO NOT SUBMIT THIS PAGE 2/8/2017 10:03:24 AM M: i IU i `:,I1 0 2 2 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency Volunteers for Youth, Inc. Received By Program(s) Volunteers for Youth, Inc. Date/Time / Section Subsection 1. Cover Page a. ® Applicant Contact Information b. ® Funding Requests c. ® Signed Application Cover Page d. ®Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. ® Agency's Years in operation b. ® Agency's Purpose/Mission c. ® Agency's Types of Services Provided d. ® Agency's Experience with Programs e. ® Other Pertinent Agency Information f. ® Schedule of Positions g. ® Living Wage h. ® Agency Budget 3. Program Information a. ® Human Services Needs Priority b. ® Type of Program A separate Section 3 is c. ® Agency Collaboration required for each program. d. ® Summary of Program e. ® Description of Identified Need f. ® Description of Population to be Served g. ® Program Staffing, Capacity, & Expertise h. ® Program Implementation Timeline i. ® Value of Investment j. ® Impact of Reduced/No Allocation k. ® Other Pertinent Information I. ® Target Population/Beneficiary Chart m. ® Work Statement n. ® Program Budget, Detail, &Cost per Individual 4. Attachments a. ® Audit: Organizations receiving $300,000 or more in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ® IRS Federal Form 990 c. ® NC Solicitation License d. ® IRS Federal Tax-Exemption Letter e. ® Certificate of Insurance f. ® List of Board of Directors g. ® Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 2/8/2017 10:03:24 AM II:2255 5 2 II DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDERS OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Volunteers for Youth, Inc. Applicant Organization's Physical Address: 205 Lloyd Street, Suite 103, Carrboro, NC 27510 Applicant Organization's Mailing Address: 205 Lloyd Street, Suite 103, Carrboro, NC 27510 Applicant Organization's Web Address: www.volunteersforvouth.orq Executive Director: Susan Worley Telephone Number: 919-9674511 E-Mail: Susan a(7valunteersforvouth.orq Tax ID Number: b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total -HS. Hill - HS County-HS Ex.Youth Afterschool Program $10,000 : $15,000 $5,000: $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects Mentoring, community service, &teen court programs $3,000 $10,000 $10,000 $23,000 Portion of program coordinators' salaries, youth activities, and general operating expenses • Totals $3,000 $10,000 $10,000 $23,000 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: G . -v7 E ecutive Director Date Signature: .i i. f l'7 Boar "• irperson Date 1:C� AGENCY INFOR *� •N 1211612016 1:33:44 PM Page 6 of 1 9 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDERS OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ( ] ►1 b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® c) Current beneficiaries of the program for which funds are being requested? ❑ ® 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 activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an, undisclosed conflict may result in the termination of any grant awarded. Signature: , I-Q3 °I7 .. �/...,t f xecuti filo Director y Date Signature: /.4 faL (3 i 2.o Board hai •erson Date AGENCY INFOR ATI• 12/16/2016 1:33:55 PM Page 7 of 1 9 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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): 12/8/1981 b) Agency's Purpose/Mission (no more than a few sentences): Volunteers for Youth (VFY) provides services to Orange County youth to integrate them into the community in ways that help them make responsible choices and recognize that they have a stake in their future. Formed in 1981 by professionals in our community who worked with court-involved youth, VFY is the only Orange County nonprofit agency dedicated to serving youth who have broken laws or who are at-risk of doing so. VFY seeks to bridge the gap between disconnected youth and the community through mentoring, community service, and teen court programs. c) Types of Services the Agency Provides (bullet format): • Mentoring — The mentoring program develops positive relationships between high need children and adolescents and caring adults through one-on-one friendships and weekly groups. • Community service and restitution - The community service and restitution program provides community service opportunities throughout Orange County for young people who have been adjudicated delinquent. • Teen court - The teen court program is an alternative court program for young people who have committed minor offenses and are referred from law enforcement, juvenile services, or the schools. d) Agency's History with Providing These Services: Volunteers for Youth operates Orange County's longest running mentoring program. Susan Worley has coordinated the program for more than 28 years. VFY began operating the juvenile community service program in 1992 at the request of the local division of juvenile services and is the only organization to have run the program in Orange County. Scott Dreyer and Alex Lowrie, the two coordinators, have been with VFY for 15 years and one year respectively. VFY has run the teen court program in Orange County for 14 years. Kate Giduz has coordinated it for more than three years. 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?) There have been no major changes at Volunteers for Youth in the past year. 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: 4 # of FTE - Paid Part-Time Positions: 0 # of Volunteers: 89 # of FTE -Volunteers:0 Agency :;i 8 ,� If 2 2 enc Information 7 ° ::� �; DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes. If yes, is this agency an Orange County Living Wage Certified Employer? Yes. If no, please explain. Agency Information 2/8/2017 10:03:24 AM I: ;i e 9 o If 2 2 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION h) Agency Budget i. Is your agency currently receiving and/or requesting other (non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) Yes. 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 Teen Court 11,746 11,926 Orange County—JCPC 30% match Community Service 26,467 26,887 Orange County—JCPC 30% match Total 38,213 38,813 Orange County Total Funding `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 • Chapel Hill Human Services • Chapel Hill Other(DO NOT include CDBG funding here) • Orange County Human Services Agency Information 2/8/2017 10:03:24 AM I:) 010 12 00 f 2 2 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • 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? Yes Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. The deficit of $2,269 is less than 1% of the agency's total revenues and not significant. iv. What is your agency's fiscal year? July 1, 2016 — June 30, 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 2/8/2017 10:03:24 AM page 11 a0 22 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Volunteers for Youth Program Primary Contact and Title: Susan Worley, Executive Director Telephone Number: 919-967-4511 E-Mail: susan@volunteersforyouth.org a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents ® Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area#3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X Family Resources Jobs/Jobs Training Food Transportation Other: Please specify Mentoring, community service, teen court 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. • Orange County Office of Juvenile Justice —VFY staff work closely with court counselors to monitor progress of youth in our program, sending monthly progress reports on individual youth to the court counselors, attending court planning meetings and sessions of juvenile court, and communicating with them frequently via phone, email, and in person conversations • A network of community service worksites including Hope Garden, Anathoth Garden, Camp Chestnut Ridge, and Boomerang — VFY staff recruit volunteers at local nonprofits who supervise court-ordered community service work of youth at their organization. VFY staff check in with the work site coordinators regularly to monitor the youth's hours and conduct. • UNC's SMART Project— In coordination with the Buckley Public Service Scholars Program at the UNC Center for Public Service, VFY recruits, screens, trains, and PROGRAM INFORMATION 2/8/2017 10:03:24 AM page I 2 00 22 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION supervises UNC students who serve as mentors to local kids while taking classes related to their mentoring experience. VFY staff attend regular planning meetings with the SMART coordinators and a SMART mentor works in VFY's office each summer to help with planning. • Family Success Alliance — Volunteers for Youth is one of a number of agencies who have come together through the Orange County Health Department's Family Success Alliance to provide services to families and children in two targeted zones in Orange County. VFY staff attends monthly planning meetings with other agency staff and FSA navigators to discuss ways to best meet needs in these zones. VFY provides one-on-one mentors and mentoring groups to youth in the zones. • Third Sector Alliance — VFY's executive director spearheads an alliance of nonprofit organizations in Orange County aimed at strengthening the voice of local nonprofits for the benefit of our clients. • Juvenile Crime Prevention Council - Volunteers for Youth is part of the Juvenile Crime Prevention Council (JCPC), made up of youth-serving professionals in Orange County who assess local youth needs, evaluate youth programs, and make decisions about how money from the North Carolina Division of Juvenile Justice should be used to meet those needs. VFY staff communicate regularly with other JCPC agencies including Boomerang, Dispute Settlement Center, and Family Advocacy Network, about the progress of shared clients and ways to best meet their needs. 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? Through mentoring, community service, and teen court services, Volunteers for Youth will address Priority Area #2: education, mentorship, and afterschool programming for 179 youth facing a variety of challenges. Mentoring: • Volunteers for Youth will recruit, screen, train, and supervise volunteers to serve as one-on-one mentors to children who could benefit from the time and attention of a caring adult role model. Volunteers in the community mentoring component will commit to getting together with their mentees for at least two hours a week for one year and those in the SMART mentoring component will commit to a minimum of two hours a week for eight months. At least 39 children will participate in the one-on-one mentoring program during the 2017- 8 fiscal year. • Group mentoring: Volunteers for Youth will host a weekly life skills group for seventh and eighth grade girls during the 2017-18 school year. A Volunteers for Youth staff person and UNC Bonner intern will lead the group, serving as mentors to at least 15 group participants. PROGRAM INFORMATION 2/8/2017 10:03:24 AM nage 11 00 f 2 2 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Community service: During the 2017-18 fiscal year, Volunteers for Youth will oversee the community service hours of at least 70 youth who are court ordered to complete community service hours. Volunteers for Youth will recruit, screen, and supervise volunteers to supervise youth doing community service at ongoing work sites throughout Orange County. Volunteers for Youth staff will plan and facilitate single day community service events for these youth throughout the year as well. Teen court: During the 2017-18 fiscal year, Volunteers for Youth will hold teen court sessions every other week, working with at least 55 youth who are referred to teen court for first time offenses. Volunteers for Youth will oversee the community service hours assigned to those youth as well as any other terms of their sentencing. Volunteers for Youth will recruit, screen, train, and supervise teen volunteers to serve as attorneys, bailiffs, jury members, and clerks. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. According to the Human Service Need Report, "Chapel Hill lacks sufficient, low- cost/free activities that positively engage children and youth especially those from at-risk and low-income households." Children and youth with little support and structure during out of school time are more likely than others to get into trouble. According to the North Carolina Division of Juvenile Justice, there were a total of 142 delinquent complaints brought against Orange County youth in 2015 (the most recent year for which statistics are available). Volunteers for Youth provides services to youth who are involved in the court system as well as those at risk of such involvement. Providing these children and youth with constructive, enriching activities outside of school time while engaging them with caring adults is an important tool in delinquency prevention. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Volunteers for Youth will work with Orange County children and youth between the ages of 8 and 15 who are referred by court counselors, police officers, school counselors, social workers, Family Success Alliance navigators, and parents. The youth will be referred either because they are involved in the court system, are first- time offenders, or are children who may be at risk for legal involvement without intervention from a program such as Volunteers for Youth. PROGRAM INFORMATION 2/8/2017 10:03:24 AM page t 'l 20 2 2 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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.) Susan Worley, mentoring coordinator of Volunteers for Youth, has a master's degree in social work, has completed a week-long training in mentoring coordination, and has attended and facilitated a number of workshops and trainings related to nonprofit administration and mentoring coordination. Scott Dreyer and Alex Lowrie, community service coordinators, have attended several trainings related to overseeing juvenile community service participants. Scott has a bachelor's degree in social work and Alex is in her second year of graduate school at the UNC School of Social Work. Kate Giduz, teen court coordinator with a bachelor's degree from Elon, has attended several trainings related to overseeing teen court programs. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. All of the services Volunteers for Youth provides are ongoing and will take place throughout the year with children and youth coming and going. Children in the one- on-one mentoring program will spend time with their mentors once a week for the period of at least one year (for those in the community mentoring program) and eight months (for those in the SMART mentoring program). Children in the group mentoring programs will see their mentors once a week throughout the school year. Youth in the community service program will perform community service hours once a week until their hours are completed. Depending on the number of hours assigned and other factors, this generally takes between two and four months but can take as long as a year. Youth will participate in the teen court program for up to three months from the time of their sentencing. (See attached timeline.) 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) Volunteers for Youth's services are aimed at prevention, doing all we can to steer children and youth to positive adulthoods. Taking part in out of school activities that are fun, educational, and beneficial while forming relationships with adult volunteers is enriching for the participants and alleviates stress for their parents. When those activities also teach youth accountability and responsibility, the value to our community is long lasting. Investing a small amount of money in youth who are at risk for challenges as adults is exponentially beneficial for society. Contrast the cost to our community of an adult who is intermittently employed and a habitual felon with the benefits of an adult who is regularly employed and law-abiding. The costs and benefits - both financial and emotional — are huge and affect individuals, families, and institutions. Investing in prevention services such as Volunteers for Youth saves our community the toll that crime takes on us all while also enhancing all our lives by helping youth reach their full potential. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Volunteers for Youth has provided services to Orange County youth since 1982. In 2009, our mentoring program received a major blow when the North Carolina Legislature did away with funding for mentoring across the state. In 2015, our PROGRAM INFORMATION 2/8/2017 10:03:24 AM 0 , ° 1 ) If 2 2 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION organization took another hit when the Triangle United Way revamped its funding structure away from member agencies. Volunteers for Youth staff has been reduced from six to four positions but we have maintained our services with the help of dedicated volunteers, interns, and staff. If Volunteers for Youth receives a reduced allocation or none at all, we will have to look at reducing much needed services, most particularly our mentoring program. Mentoring is one of the most commonly cited needs of parents, including those in the Family Success Alliance zones, so we are hopeful that we can continue our highly effective program with the funding requested. k) Include any other pertinent information. PROGRAM INFORMATION 2/8/2017 10:03:24 AM page 1 6 00 22 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information I) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 88 91 100 Female 84 88 95 Total 172 179 195 Ethnicity African-American 63 65 70 American Indian or Alaska Native Asian 8 3 5 Caucasian 88 104 113 Native Hawaiian or other Pacific Islander Other: specify_Biracial 13 7 7 Total 172 179 195 Of the above, how many Hispanic/Latino 32 42 45 Of the above, how many non-Hispanic/Latino 140 137 150 Total 172 179 195 Age 0-5 years 6-18 years 172 179 195 19-50 years 51+ years Total 172 179 195 Geographic Location Alamance County Chatham County Durham County 4 2 2 Wake County Orange County Breakdown Chapel Hill Public Housing (estimate) 10 10 10 Town of Chapel Hill (Non-Public Housing) 71 73 80 Town of Carrboro 10 17 20 Town of Hillsborough 39 40 42 City of Mebane (Orange County) 11 9 10 Orange County (Outside Municipalities) 27 28 31 Total 172 179 195 PROGRAM INFORMATION 2/8/2017 10:03:24 AM p a g g °' 7" a 1 2 2 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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 Volunteers for Youth 1. Program Activity Name Mentoring Program Goal At least 80% of youth will complete their mentoring matches. Performance Measures Track client progress through contact with mentors and clients. Previous Year Program Results 98% of youth completed their mentoring matches. Current Year Estimated Results 90% of youth will complete their mentoring matches. Next Year Projected Results 85% of youth will complete their mentoring matches. 2. Program Activity Name Community Service Program Goal At least 80% of youth will have no new charges while in the program. Performance Measures Track client progress through contact with youth, court counselors. Previous Year Program Results 93% of youth had no new charges while in the program. Current Year Estimated Results 90% of youth will have no new charges while in the program. Next Year Projected Results 85% of youth will have no new charges while in the program. 3. Program Activity Name Teen Court Program Goal At least 80% of youth will have no new charges while in the program. Performance Measures Track client progress through contact with youth, court counselors. Previous Year Program Results 94% of youth had no new charges while in the program. Current Year Estimated Results 90% of youth will have no new charges while in the program. Next Year Projected Results 85% of youth will have no new charges while in the program. 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 10:03:24 AM 0 ' ago °" 8 00 22 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Volunteers for Youth, Inc. Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 37,024 $ 40,000 $ 46,500 16% Agency Generated Revenue (fees) $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ 2,500 $ 2,750 $ 3,000 9% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 8,000 $ 9,000 $ 10,000 11% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ - $ 7,500 $ 8,000 7% Other- Orange County $ 37,514 $ 38,213 $ 38,813 2% Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ 15,281.00 $ 13,500.00 $ 14,400.00 $ 0.07 State Government $ 125,084.00 $ 127,379.00 $ 129,379.00 $ 0.02 Federal Government(CDBG/HOME/etc.) $ 4,000.00 $ 3,500.00 $ (1.00) Private Foundation Grants $ 22,500.00 $ 15,000.00 $ 20,000.00 $ 0.33 Other Revenue $ - $ - $ - 0 Total Agency Revenue $ 251,903 $ 256,842 $ 270,092 5% AGENCY EXPENSES Compensation $ 179,482 $ 186,530 $ 189,213 1% Rent& Utilities $ 27,944 $ 28,434 $ 28,644 1% Supplies & Equipment $ 13,245 $ 13,000 $ 14,000 8% Travel &Training $ 2,653 $ 2,100 $ 2,535 21% Other Expenses: $ 30,848 $ 28,000 $ 35,700 28% Total Agency Expenses $ 254,172 $ 258,064 $ 270,092 5% SURPLUS/(DEFICIT) FOR PERIOD: $ (2,269)1 $ (1,222)1 $ - I 100% FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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. • Audit- $4,600 • Fundraising - $4,793 • Workers compensation insurance - $5,163 • Liability insurance - $3,381 • Youth activities - $2,263 • Girls group coordinator- $3,000 • IT and graphic design support- $920 • Internet - $1,275 • Repairs & maintenance - $982 • Restitution payments- $2,467 • Volunteer training and support- $877 • Professional development- $1,113 3. This program budget represents what percent of the agency budget? 100% 4. COST PER INDIVIDUAL PROGRAM INFORMATION 2/8/2017 10:03:24 AM F' a g e 19 90 22 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program $254,172 $258,064 $270,092 Total # of Individuals 172 179 195 Cost Per Individual $1,478 $1,442 $1,385 PROGRAM INFORMATION 2/8/2017 10:03:24 AM II ' age 2 If DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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 (PDF), about exemptions. If exempt per N.C.G.S. § 131 F-3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax-Exemption Letter A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 — June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. DO NOT SUBMIT THIS PAGE 2/8/2017 10:03:24 AM u 11 2 2 1 0 If 2 2 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Limits for Coverage Compensation A - Statutory State Limits for Coverage A - Limits for Coverage A - NC, for each Statutory State NC, for Statutory State NC, for employee each employee each employee Limits for Coverage Limits for Coverage B - Limits for Coverage B - B - Employers Employers Liability of: Employers Liability of: Liability of: $100,000 Each Occurrence $500,000 each $1 million Each $100,000 BID for each accident, $500,000 Occurrence employee BID for each employee $1,000,000 BID2 $500,000 BID limit $500,000 for BID limit limit Commercial $100,000 Property General Damage Liability $1 million Each Liability $1,000,000 Bodily $1 million Each Occurrence Occurrence Injury Property $2 million Aggregate y and Pro p y $2 million Aggregate Damage Limit Automobile Not Applicable $1 million Each Occurrence $500,000 Each Liability Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts webpage for more information about the County's risk assessment procedures. f) List of Board of Directors Provide the following information about each board of director's member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. g) Solid Waste Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency's FY 2016-17 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. DO NOT SUBMIT THIS PAGE 2/8/2017 10:03:24 AM g 2, 2 2 ) If 2 2 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 EXHIBIT"B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Volunteers for Youth,Inc. Program Name: Volunteers for Youth Funding Award: $8,750 Outline how the agency will spend Orange County's funding award. Expense Description_ _ Amount 10%of executive director/mentoring coordinator's salary and benefits _ $5,912 20%of youth activities $550 5%of office rent $1,422 5%of insurance $186 10%of audit $480 10%of office supplies $200 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018'. • Mentoring Program: Year-long program providing mentors to high risk youth • Community service: 3 to 12 month program overseeing community service hours of court- referred youth • Teen Court: 3 to 6 month program providing alternative court experience to first time youth offenders 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 Enrollment in mentoring program 45 Enrollment in community service program • 140 Enrollment in teen court program 50 • Percentage of mentoring program participants completing their program 80% commitment Percentage of community service participants with no new charges while in the 75% program Percentage of teen court participants with no new charges while in the program 75% DocuSigned by: Executive Director 8/31/2017 43B863 .B E. Certified by: e_- _,Ar Title: E ECLT11E D1kZ Date: 7/C 07 (Provider's Signature) DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 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: Certified by: Title: Executive Di rector Date: 8/31/2017 y• F (Provider's Signature) (Volunteers for Youth) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:A13A145D-D67A-4FF7-ABA9-312E380D8DD9 • A o® CERTIFICATE OF LIABILITY INSURANCE DA' ( IKIDO YYY) 4...-----' 7/10/2017 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(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER jE CT Anita M.Chick, CIC, CISR,CIIP Marsh&McLennan Agency LLC PHONE 336-.,899-2402 FAX 212-607-6550 1400 Eastchester Drive, St 200 (Arc No Fotp (A/C,No): High Point NC 27265 SS,Anita.Chick @marshmma.com INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Alliance Member Services 10023 INSURED VOLUN-3 INSURER B:Accident Fund General Ins Co Volunteers for Youth, Inc. INSURER C Susan Worley — 205 Lloyd St.Suite 103 INSURER D: Carrbaro NC 27510 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:848171904 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 INSD WVD POLICY NUMBER IMMPOUCY,YYYY) (MMl Dnrnm LIMITS A x COMMERCIAL GENERAL LIABILITY Y 1 2016-20727 10/1/2018 10/1/2017 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED • CLAIMS-MADE 1 X J OCCUR' PREMISES(Ea occurrence) ,$500,000 MEC EXP(Any one pen3on) $20,000 , ' PERSONAL&ADV INJURY $1,000,000 • • • GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 , POLICY PET LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 2016-20727 10/1/2016 10/1/2017 COMBIN)SINGLE LIMIT $4 000 000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X AIRED X NON S NED PROPERTY dn).DAMAGE $ AUTOS ONLY AUTOS DNLY (Per accident). I $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LWB CLAIMS-MADE AGGREGATE $ • DED I j RETENTION$ $ — B WORKERS COMPENSATION 1 WCV6116809 10/1/2016 10/1/2017 X PER I 0TH- ER AND EMPLOYERS'LIABILITY YIN STA ...... ANY PROPRIETOR/PARTNER/EXECUTIVE N!A E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under . DESCRIPTION OF OPERATIONS below , E.L.DISEASE-POLICY LIMIT $500,000 A Improper Sexual Conduct 2016-20727 10/1/2016 10/1/2017 Unit 500,000 DESCRIPTION Of OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is moulted) Certificate holder is recognized as additional insured in respects to General Liability when required by written contract with the named insured. CERTIFICATE HOLDER CANCELLATION 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 POUCY PROVISIONS. Hillsborough NC 27278 - AUTHORIZED REPRESENTATIVE i,. ::,t21.4664".4.." giticisi I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD