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2017-559-E Finance - Ligo Dojo of Budo Karate - Outside Agency Performance Agreement
DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 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 Ligo Dojo of Budo Karate, a not-for-profit corporation, located at 630 Weaver Dairy Rd#107, Chapel Hill,NC 27514 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Ligo Dojo of Budo Karate 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 3000 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 750. 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. (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 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. (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 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. (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 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 Ligo Dojo of Budo Karate 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: (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 County: Finance &Administrative Services Provider: Ligo Dojo of Budo Karate Orange County 630 Weaver Dairy Rd#107 Post Office Box 8181 Chapel Hill,NC 27514 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable,it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. 18. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 19. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For ro as bf of the Provider „T 10/10/2017 �"-- 1_5alEn054E ME7 Date (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 For ub J f of Orange County Government 1jOVA.UUt A-AJ4 t4 U'S(LI 10/12/2017 06379949755E477 Bonnie Hammersley, County Manager Date (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Society for the Betterment of the Human Condition through the Training, Instruction and Propagation of Buda Karate (d.b.a. Ligo Dolo of Budo Karate) Applicant Organization's Physical Address: 630 Weaver Dairy Road Chapel Hill NC 27514 Applicant Organization's Mailing Address: 2418 A Millwood Court Chapel Hill NC 27514 Applicant Organization's Web Address: Executive Director: Nathan Ligo Telephone Number: 919-923-6915 E-Mail: nligo a(7hotmail.com 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 L.HS County-HS Ex ;Youth Afterschool Program' $'10,000 $'15,000 $5000 $$0 000.:: Aftrschoel Program Coordinator salary and materials f©r youth:activities and:projects Young Warriors Program. Program Coordinator $4,000 $4,000 ;`. $4,000 $12,000 salary, program supplies, facility rent, and expenses. Totals $4,000 $4,000 $4,000 $12,000 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 '; " P ) / ._ Executive-Dire?tor Date f=' i t f i Signature: # ; Board ohairperson Date AGENCY INFORMATION 1/31/2017 11:45:20 AM Page 1 of 2 0 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® 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 ,7X,AA,:, , i � / ' I Executive Director„ Date I / t , ' Signature Board Chairperson Date AGENCY INFORMATION 1/31/2017 11:45:20 AM Page 3 of 2 0 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT 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): July 1999 b) Agency's Purpose/Mission (no more than a few sentences): Our mission is to.1. To strengthen the minds, bodies and hearts of young people through karate training, because hard physical training leads to increased spiritual strength and patience, which in turn leads to the ability to make better life decisions. 2. To deepen relationships between people of diverse backgrounds through hard training, an inherent 'equalizer' between people. 3. To strengthen American communities (starting in North Carolina, especially in Durham and Orange Counties) by thus strengthening individuals who might then serve as role models for other members of the community. 4. To create individuals who are 'community minded' and open minded people who VALUE works for the sake of community rather than merely for personal economic and social advancement. c) Types of Services the Agency Provides (bullet format): • This project allows at-risk and financially challenged youths in Chapel Hill/Carrboro/Orange County to participate in an athletic activity that is inherently life and character redefining, and inherently conducive to the formation of a leader-type mentality. Participating teens will see improvements in confidence, self-discipline and physical health. They will receive the support that they need to begin to make a better set of decisions in life and, in so doing, they will become either deliberate or unknowing role models for other similarly challenged members of the community. • Referred youth attend 2-5 two-hour classes per week for 10 weeks. Court referred kids are often ordered to attend 20 classes. Classes are afternoons at 5 pm for younger kids, and 6:30 pm for teens and adults. Program staff maintains client files according to JCPC (Juvenile Crime Prevention Council) standards, attends JCPC meetings and court planning meetings, and interacts with referring counselors to achieve the best possible result for all program participants. • Karate is an activity that teaches all students to be more "upstanding" in terms of personal behavior and personal presentation; it teaches them to stand up taller, walk lines in life more straight than before; youth interact with figures of authority in a more respectful manner improving pro-social skills and supporting factors—including • physical health, confidence, self-esteem, self-discipline, anger management and conflict resolution—youths become less inclined to get themselves into trouble with crime, gangs, drugs, etc. d) Agency's History with Providing These Services: We have been operating our Young Warriors Program consistently for 8 years, funded by grant-making bodies including: the NC Governor's Crime Commission (GCC), Durham and Orange County's Juvenile Crime Prevention Councils (JCPC), Triangle Community Foundation (TCF), the City of Durham, the Cities of Chapel Hill and Carrboro, Orange County, Wells Fargo Foundation, the Mary Duke Biddle Foundation, Strowd Roses Agency Information 1/31/2017 11:45:20 AM Page 4 o f 2 0 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Foundation, and others. The Young Warriors Program accepts referrals of disadvantaged youth from over a dozen agencies in Durham and Orange County. Greater than that, however, would be a list of the successful programs we've run under the auspices of the NC Dept. of Juvenile Justice which we list here (each one represents a grant received) and the fact that we have measured success rates showing our accomplishments in the lives of the youths we have taught: Young Warriors (YW) JCPC Durham '09-10, YW JCPC Durham '10-'11, YW JCPC Durham '11-'12, YW JCPC Orange '11-1012, YW CBT Level II Program '11-'12, YW JCPC Durham '12-'13, YW JCPC Orange '12-'13, YW CBT Level II Program '12-13, YW JCPC Durham '13-'14 (current year), YW JCPC Orange '13-'14, YW CBT Level II Program '13-'14, ), YW JCPC Orange '14-'15, YW, YW JCPC Orange '15-'16, JCPC Orange '16-'17 (current year) . 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?) Chapel Hill/Carrboro native Nathan Ligo founded The Society for the Betterment of the Human Condition through the Training, Instruction and Propagation of Budo Karate in 1999, and opened Ligo Dojo of Budo Karate in Durham (a d.b.a. name for the same 501.c.3 nonprofit) in 2006, and now our second location, Ligo Dojo of Budo Karate in Chapel Hill, in 2011. It has become a remarkably common occurrence for us that parents tell us "my child is SO much better behaved now at home," or "my child's teacher at school told us yesterday how she's doing so much better in class, and we know its all because of karate!" or even "my child hasn't gotten in a single fight at school since he's been here at the dojo!" Beyond this type of recognition we have been recognized in numerous ways. ED Nathan Ligo was interviewed on ABC news (interview available on our website), the Raleigh N&O named him Tar Heel of the Week one week in 2012, and Governor Perdue wrote him a handwritten card congratulating him for his organization's successes. In 2010 Triangle Community Foundation awarded us its state-wide What Matters Innovation Award for Nonprofit Excellence. 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: 1 # of FTE - Paid Part-Time Positions: 1 # of Volunteers: 2 # of FTE -Volunteers: 1 g) Living Wage Does this agency pay permanent employees a minimum '? (Yes/No) Yes If yes, is this agency an �: 7 No Agency Information 1/31/2017 11:45:20 AM Page 5 of 20 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION If no, please explain. No, since we don't hire full-time employees other than our executive director, this is not applicable. Our one employee, Executive Director Nathan Ligo, does make a living wage. Our organization is dedicated to promoting a living wage and we would certainly become certified should we ever grow to where were hiring additional full-time employees. Agency Information 1/31/2017 11:45:20 AM Page 6 of 20 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT 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 E ;Affordable Rental l $20,0{0' Carrboro Affordable Housing l ehabilitation Agency Administration $15,000 $15,000 Carrboro 'Other' l� Total $ 5,000 $35,000 Carrboro Total Finding Local match for Orange $3600 $3600 Orange County (We do not have County JCPC funding (We do to request these funds. If we are not have to request these funded by JCPC, Orange County funds. If we are funded by automatically provides the JCPC, Orange County match.) automatically provides the match.) *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues o Private Donations o Program Generated Revenue Agency Information 1/31/2017 11:45:20 AM Page 7 of 2 0 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Ligo Dojo of Budo Karate Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 2,500 $ 3,500 $ 3,500 0% Agency Generated Revenue (fees) $ 77,130 $ 80,000 $ 90,000 13% Local Government Grants: Human Services-Town of Carrboro $ 2,000 $ 2,000 $ 4,000 100% Other-Town of Carrboro $ - $ - $ - 0 Human Services -Town of Chapel Hill s $ 2,000 $ 4,000 100% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ 2,000 $ 2,000 $ 4,000 100% Other- Orange County $ 3,600 $ 3,600 $ 3,600 0% Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants 111111111111111111111 OC JCPC $ 19,000.00 $ 19,000.00 $ 19,000.00 $ - State Government $ - $ - $ - 0 T Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 4,000.00 $ 2,000.00 $ 2,000.00 $ - Other Revenue $ - $ - $ - 0 Total Agency Revenue $ 110,230 $ 114,100 $ 130,100 14% AGENCY EXPENSES Compensation $ 33,731 $ 34,000 $ 48,000 41% Rent& Utilities $ 38,000 $ 38,500 $ 39,000 1% Supplies& Equipment $ 2,000 $ 4,500 $ 6,000 33% Travel &Training $ 5,000 $ 5,000 $ 5,000 0% Other Expenses: $ 31,499 $ 32,100 $ 32,100 0% Total Agency Expenses $ 110,230 $ 114,100 $ 130,100 14% SURPLUSI(DEFICIT) FOR PERIOD: $ - I $ - I $ - I 0 FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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? Neither Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or.Deficit, and significant changes. iv. What is your agency's fiscal year? July 1, 2017 — June 31, 2018 for grant service purposes, although it is Jan 1 to Dec 31 for tax reporting pruposes. (Example: July 1, 2016 through June 30, 2017) Agency Information 1/31/2017 11:45:20 AM Page 8 of 20 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Young Warriors Program Program Primary Contact and Title: Nathan Ligo— Executive Director Telephone Number: 919-923-6915 E-Mail: nligoahotmail.com 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 N ._: erghborhoods/Residerlts" Affordable Housing Affordable Healthcare Education Family Resources Jobs/Jobs Training Food Transportation Other: Yes After-School Activities Sports and Arts Activities c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. We currently accept referrals from many agencies serving disadvantaged youth. They have included but are not limited to: • The Department of Juvenile Justice (court-involved youth) • Carolina Outreach (mental health) • Big Brothers and Big Sisters of the Carolina's (mentoring) • Exchange Club Family Center • Carolina Outreach • El Centro Hispano • Chapel Hill Refugee center • We continue to be popular among mental health agencies. • Law enforcement and school social workers can also make referrals. PROGRAM INFORMATION 1/31/2017 11:45:20 AM Page 9 of 2 0 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a TownlCounty priority/goal? Ligo Dojo's outpost in Orange County at Chapel Hill's Cedar Falls Shopping Center has become a rare, and much needed facility in Orange County. Through it we bring positive youth development programming to a community that DOES have a demographic of at risk kids, and expected corresponding problems including juvenile crime, drug abuse and delinquent activity. As we had been in Durham for years, we are working with Juvenile Court referrals who are on diversion plans, with those under court supervision, and with those on post-release supervision, as well as "prevention kids" who are at-risk due to socio-economic background as well as other conditions but are not yet involved in delinquent activity. We are actively working with school social workers from collaborating agencies who can identify youth who can benefit from pro-social activities and environments. Our Young Warriors Program has operated on an ongoing basis, first in Durham and later in Chapel Hill, since 2009. Program operates on a year-round basis. Referred youth attend 2-5 two- hour classes per week for 10 weeks. Court referred kids are often ordered to attend 20 classes. Classes are afternoons at 5 pm for younger kids, and 6:30 pm for teens and adults. One rare feature of our programming (as compared to other JCPC programs) is that we invited kids to continue their training beyond completion of their ten week assignment. We have kids sometimes for years, rather than weeks, and these kids, especially, are transformed. e) Describe the community need or problem to be addressed in relation to the < haoei.."iiii Orance Cotes ' °, B CC Goals and E-r"iontieS, Town of oro 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. Orange County JCPC has determined that delinquent activity, presence of drugs, and occurrence of juvenile crime are priority needs to be addressed. Needs assessment by Juvenile Justice Court counselors indicate that 9% of juveniles assessed at intake have substantial gang involvement, and 62% of youth have serious school behavior problems. Agencies currently involved in delinquency intervention and suppression efforts lack features that can provide sufficient impact. One reason why young people become involved in delinquent activity is the lack of constructive after-school alternatives. This project will allow Chapel Hill/Carrboro and Orange County's at-risk youth to participate in a constructive after-school activity that exists as an enticing alternative to the gang/crime norm within underprivileged communities. JCPC has additionally determined that and 72% of adjudicated youth come from homes where parents/guardians have marginal to inadequate supervision skills. The Young Warriors program provides an opportunity for young people to train WITH their parents in an activity that has been shown to make people of all ages stronger and to bring parents and their kids closer together, and to a point of better shared understanding. That said, the program is not a miracle cure, and although we invite and encourage parents to participate, the frequency with which parents of court- referred youth do so is LESS than the frequency with which the parents of prevention youth do. PROGRAM INFORMATION 1/31/2017 11:45:20 AM Page 10 of 2 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The program is open to all youths, age 6 or greater, who are disadvantaged, or otherwise at-risk of becoming involved with delinquent behavior, or who already have become involved with delinquent behavior. Participating youths are referred by counselors of cooperating agencies. Due to our contract with JCPC (Juvenile Crime Prevention Council channeling NC Department of Juvenile Justice funds) we prioritize Juvenile Court Referred youths. However, we have seen a dramatic decrease in the number of kids (total) in Orange County who are becoming court involved. This reduction is a direct result of programs like ours that ALSO serve kids on the front end, i.e. kids who are at-risk, but who are not yet engaged in delinquent activities. Therefore, we are currently serving a group that is less that 50% court referred, and the greater service population comes from needy echelons of our community who are at-risk of engaging in future delinquent activities due to conditions such a mental health or social-economic background. This past year all of our kids were referred from the following sources: Juvenile Court, El Centro Hispano, mental health agencies, family referrals. These are only 4 sources, but we are open to accepting referrals from nearly any agency working with at-risk or underprivileged youth. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Program Director, Nathan Ligo coordinates the referral process. Nathan attends monthly meetings with court counselors, and communicates recruitment opportunities with local agencies. He conducts informational sessions at El Centro and other agencies when requested. Youth classes are taught by head instructor, Nathan Ligo, or by unpaid volunteer adult instructors who have been trained within the program (our adult program) and who meet all requirements laid out by JCPC (NC Dept of Juvenile Justice). All class instruction is overseen by Nathan Ligo. Client file maintenance and reporting requirements are handled according to JCPC requirements. Long- running Young Warriors Program staff have background checks on file, according to JCPC (Juvenile Crime Prevention Council) guidelines. Correct behavior and decorum is a hallmark of our program and of Japanese Karate in general. Nathan Ligo has been directing the Young Warriors Program in Durham and Chapel Hill for 8 years, and has been recognized as N&O's Tarheel of the Month, and was commended by our former governor, Beverly Perdue, for his work in the community with youths through the Young Warriors Program. Nathan Ligo is supported by an array of volunteer and/or part time staff trained through multi-year participation in our adult classes. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Our Young Warriors Program has operated on an ongoing basis, first in Durham and later in Chapel Hill, since 2009. Program operates on a year-round basis. Referred youth attend 2-5 two- hour classes per week for 10 weeks. Court referred kids are often ordered to attend 20 classes. Classes are afternoons at 5 pm for younger kids, and 6:30 pm for teens and adults. One rare feature of our program, when compared to other JCPC programs, is out ability to keep our kids active and participating long beyond completion of the proscribed 10-week program. Particularly for our younger prevention kids, it is not unusual for us to keep them engaged for years, rather than weeks. 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) PROGRAM INFORMATION 1/31/2017 11:45:20 AM Page II of 20 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Karate, when taught correctly, is an activity that teaches all students to be more "upstanding" in terms of personal behavior and personal presentation; students will learn to stand up taller, walk lines in life more straight than before, interact with figures of authority in a more respectful manner improving pro-social skills and supporting factors—including physical health, confidence, self- esteem, self-discipline, anger management and conflict resolution—youths become less inclined to get themselves into trouble with crime, gangs, drugs, etc. JCPC funds a continuum of services which work with at-risk and court referred kids. Coordinated by Juvenile Court counselors kids receive "wrap-around" services which support kids from multiple avenues all at the same time. The Young Warriors program, provided a social-skills building challenge program, has been part of JCPC's continuum of services for years, and our presence on that list is not accident. At JCPC we (North Carolina Juvenile Justice) have a performance measurement tool called SPEP (Standardized Program Evaluation Protocol) which evaluates the effectiveness of a program and our SPEP score was the highest from all the Orange County JCPC programs, including those that you recommended for funding, and several of our sister programs had actually fairly low scores. The measurable objectives, that we are required to record for JCPC, including especially recidivism, is very a very robust measurement tool regarding the progress that our kids make. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. In the past four years we have undergone a dramatic transformation from an organization that virtually had surplus grant money (we did very well in Durham before changes in the State legislature meant that we were no longer eligible for certain funding streams) to one in which we are much more independent, thanks to the dues paid by non-referred members. However, we have struggled with this transition, because our nonprofit work and model presents an inherent stumbling block when it comes to building a robust membership in terms of students from affluent pro-social families. They look at us when deciding to sign up their kids or not, and ask, "do my kids really fit in here?"Although our sustainability is strengthening, we are STILL struggling to make ends meet, we have staff that is being paid less than in the past, and workers who are volunteering who used to be paid. At the same time, we have experience in our HSAB hearings, telling the board members how tight our budget has become, and being asked in response why we don't ask for more money than the $2000 (x3) that we've requested every year until now. In other words, we heard that as saying "you should have applied for more money?" This year we adjust our funding request to $4000 (x3) in order to take a step towards humanizing our staff, We will resume paying a part-time salary to a volunteer worker who USED TO BE a paid employee, but who remained due to dedication our mission, even though she was not paid. It is our belief that this new request amount ($12,000 rather than $6,000) will move us to being more in line with a sensible funding stream, rather than a survival one. However, to answer the question, if we were not funded to the full amount requested, we would survive. k) Include any other pertinent information. PROGRAM INFORMATION 1/31/2017 11:45:20 AM Page 12 of 20 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT 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 18 15 15 Female 12 15 15 Total 30 30 30 Ethnicity African-American 9 10 10 American Indian or Alaska Native Asian 3 4 4 Caucasian 10 8 8 Native Hawaiian or other Pacific Islander Other: specify 8 8 8 Total 30 30 30 Of the above, how many Hispanic/Latino 8 8 8 Of the above, how many non-Hispanic/Latino 22 22 22 Total 30 30 30 Age 0-5 years 6-18 years 30 30 30 19-50 years 51+ years - Total 30 30 30 Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing 6 6 6 Town of Chapel Hill (Non-Public Housing) 6 7 7 Town of Carrboro 10 11, 11 Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) 8 6 6 Total 30 30 30 PROGRAM INFORMATION 1/31/2017 11:45:20 AM Page 1 3 of 20 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT 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 I Program Activity, which should be SMART(Specific, Measurable, Achievable, Relevant, and Time-bound. Click on 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 Young Warriors Program 1. Program Activity Name 2-5 classes per week for ten weeks. Program Goal 90% Participants will have no new complaints during program participation. Performance Measures See following page Previous Year Program Results '100% C urrent Year Estimated Results 100%YTD Next Year Projected Results 100% 2. Program Activity Name 2-5 classes per week for ten weeks. Program Goal 90%of children admitted will participate in a promotion test at the end of their term(s) and will receive the validation of new belt color/promotion. Performance Measures See following page Previous Year Program Results 92% Current Year Estimated Results 100% YTD Next Year Projected Results 95% 3. Program Activity Name 2-5 classes per week for ten weeks. Program Goal 90%Participants completing the program will demonstrate a reduction in problem behaviors for which they were referred by termination. Performance Measures See following page Previous Year Program Results 84.62% (this period goals were 80% Current Year Estimated Results 100% YTD Next Year Projected Results 90% 4. Program Activity Name 2-5 classes per week for ten weeks. Program Goal 90% Participants completing the program will demonstrate improvement in targeted skills as specified in the individual service plan by termination. PROGRAM INFORMATION 1/31/2017 11:45:20 AM Page 14 of 20 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Performance Measures See following page Previous Year Program Results 92.31% (this period goals were 80% Current Year Estimated Results 100% YTD Next Year Projected Results 90% Our performance measures would not fit in the format provided above. They are as follows: • We track student attendance online • A designee of referred youth fills out a person ISP document (Individual Service Plan) that identifies what skills are identified as needing to be addressed (for example: self-discipline, ability to focus, pro-social interaction). These plans are reviewed and signed by designee at the end of referred youth's participation. • Information from JCPC tracking database • Central to our ability to evaluate our program's success is collaboration with counselors from referring agencies including Orange County Juvenile Court counselors. • We already have a system in place for tracking measurable goals and objectives for the juvenile delinquency prevention grant-making bodies to which we already have to answer. PROGRAM INFORMATION 1/31/2017 11:45:20 AM Page 15 of 20 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT 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. 3. This program budget represents what percent of the agency budget? 29% 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. 1 1 f fir ed 161? Pro d 2017 w?I.B. Total Cost of Program 3Q689 31,700 39,400 Total # of Individuals 30 30 30 Cost Per Individual 1,022 1,056 1,313 PROGRAM INFORMATION 1/31/2017 11:45:20 AM Page 16 of 20 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Ligo Dojo of Budo Karate Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 2,500 $ 3,500 $ 3,500 0% Agency Generated Revenue (fees) $ 77,130 $ 80,000 $ 90,000 13% Local Government Grants: Human Services -Town of Carrboro $ 2,000 $ 2,000 $ 4,000 100% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 2,000 $ 4,000 100% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 2,000 $ 2,000 $ 4,000. 100% Other-Orange County $ 3,600 $ 3,600 $ 3,600 0% Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants OC JCPC $ 19,000.00 $ 19,000.00 $ 19,000.00 $ - State Government "$ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 4,000.00 $ 2,000.00 $ 2,000.00 $ - Other Revenue $ - $ - $ - 0 Total Agency Revenue $ 110,230 $ 114,100 $ 130,100 14% AGENCY EXPENSES Compensation $ 33,731 $ 34,000 $ 48,000 41% Rent& Utilities $ 38,000 $ 38,500 $ 39,000 1% Supplies& Equipment $ 2,000 $ 4,500 $ 6,000 33% Travel &Training $ 5,000 $ 5,000 $ 5,000 0% Other Expenses: $ 31,499 $ 32,100 $ 32,100 0% Total Agency Expenses $ 110,230 $ 114,100 $ 130,100 14% SURPLUS/(DEFICIT) FOR PERIOD: $ - 1 $ - I $ - 1 0 FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 EXHIBIT "B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Ligo Dojo of Budo Karate Program Name: Young Warriors Funding Award: $3,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Facility rent and program support expenses $3,000.00 Program Services Outline the critical.services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Instills discipline, creates self esteem, and physical and mental health in referred, disadvantaged youth through martial arts training. • Youth attend 10 or more weeks of karate training two or more times per week • Diverse training environment for youth and families 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. Anticipated Performance Measures Results Track student attendance online 100% Participation successful with no new complaints during program participation 90% Participants demonstrating a reduction in problem behaviors for which they were referred 90% Participants will demonstrate improvement in targeted skills as specified in the individual 90% service plan. : Uocusigned-by: lit jrr liexecutive director 10/10/2017 15A1FD054FAQ4E7 Certified by ( ,.._..J Title: ) E ,v. .°7 `e '' t ` Date Lt . .°(Provider's Signat4re) < DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 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: executive director 10/10/2017 Certified by: a ,S,t A EM94Fa z_ Title: Date: (Provider's Signature) (Ligo Dojo of Budo Karate) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID: C2E9E60D-5370-4D81-B634-C12E6C6B9DB9 ACOR°1 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/24/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Mass Merchandising K&K Insurance Group, Inc. PHONE FAX 1-260-459-5940 (A/C, Ext): / , o): 1712 Magnavox Way E-MAIL Fort Wayne IN 46804 ADDRESS: info@martialartsinsurance-kk.com PRODUCER CUSTOMER ID: INSURER(S)AFFORDING COVERAGE NAIC# INSURED 2000700572 CP#1054 INSURER A: Nationwide Mutual Insurance Company 23787 Society for the Betterment of the Human Condi INSURER B: DBA: Ligo Dojo of Budo Karate INSURER C: 2518 A Millwood Court INSURER D: Chapel Hill, NC 27514 INSURER E: A Member of the Sports, Leisure&Entertainment RPG INSURER F: COVERAGES CERTIFICATE NUMBER:2000316273 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY X 6BMAS0000005853700 09/20/16 09/20/17 EACH OCCURRENCE $1,000,000 12:01 AM 12:01 AM DAMAGE TO RENTED $500,000 CLAIMS-MADE X OCCUR PREMISES(Ea Occurrence) MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $5,000,000 POLICY PROJECT LOC PRODUCTS–COMP/OP AGG $1,000,000 OTHER: PROFESSIONAL LIABILITY $1,000,000 LEGAL LIAB TO PARTICIPANTS $1,000,000 A AUTOMOBILE LIABILITY 6BMAS0000005853700 09/20/16 09/20/17 COMBINED SINGLE LIMIT(Ea $1,000,000 12:01 AM 12:01 AM accident ANY AUTO BODILY INJURY(Per person) OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY X AUTOS ONLY (Per accident) X Not provided while in Hawaii UMBRELLA OCCUR LIAB EACH OCCURRENCE EXCESS LIAB -CLAIMS-MADE AGGREGATE DED n RETENT-ION WORKERS COMPENSATION N/A PER STATUTE' 'OTHER AND EMPLOYERS'LIABILITY — ANY PROPRIETOR/PARTNER/ Y/N E.L.EACH ACCIDENT EXECUTIVE OFFICER/MEMBER EXCLUDED?(Mandatory in NH) E.L.DISEASE–EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE–POLICY LIMIT A MEDICAL PAYMENTS FOR PARTICIPANTS 09/20/16 09/20/17 PRIMARY MEDICAL 6BMAS0000005853700 12:01 AM 12:01 AM EXCESS MEDICAL $150,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Location#1:630 Weaver Dairly Rd, Suite 107, Chapel Hill, North Carolina 27514; Location#2:2518 A Millwood Court, Chapel Hill, North Carolina 27514 Martial Arts style(s): Karate The certificate holder is added as an additional insured, but only for liability caused, in whole or in part,by the acts or omissions of the named insured. Sexual Abuse or Sexual Molestation Liability-$1,000,000 Each Occurrence(included above)/$1,000,000 Aggregate(included above) CERTIFICATE HOLDER CANCELLATION Orange County SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Attn: Risk Management EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH 200 South Cameron Street THE POLICY PROVISIONS. P.O. Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE Sponsor � iF: :.��.,� -cam� ©1988-2015 ACORD CORPORATION. All rights reserved. Coverage is only extended to U.S.events and activities. " NOTICE TO TEXAS INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD