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HomeMy WebLinkAbout2017-561-E Finance - Historical Foundation of Hillsborough and Orange County - Outside Agency Performance Agreement DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 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 Historical Foundation of Hillsborough and Orange County, a not-for-profit corporation, located at 201 N. Churton Street, Hillsborough, NC 27278 ("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 Historical Foundation of Hillsborough and Orange County 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 6699 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 1674.75. 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. (Historical Foundation of Hillsborough and Orange County) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 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. 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 (Historical Foundation of Hillsborough and Orange County) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 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. 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 (Historical Foundation of Hillsborough and Orange County) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 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 Historical Foundation of Hillsborough and Orange County 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 (Historical Foundation of Hillsborough and Orange County) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 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: County: Finance &Administrative Services Provider: Historical Foundation of Orange County Hillsborough and Orange County Post Office Box 8181 201 N. Churton Street Hillsborough,NC 27278 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 and on behalf of the Provider (Historical Foundation of Hillsborough and Orange County) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 CDocuSigned by: CAilvtAils_e_ '" a 9/25/2017 7A9,QB35B1D6n5G Date For an Pise iii#ftvf Orange County Government IblAAA, , t'a.mwte-rS(u1 10/12/2017 f1637QA4R755F477 Bonnie Hammersley, County Manager Date (Historical Foundation of Hillsborough and Orange County) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FY 2017-2018 Outside Agency Funding Application HUMAN SERVICES • ORANGE COUNTY • TOWN OF CARRBORO • TOWN OF CHAPEL HILL Orange County (OC) Town of Carrboro (CA) Town of Chapel Hill (CH) 200 S. Cameron Street 301 W. Main Street 405 Martin Luther King, Jr. Blvd. Hillsborough, NC 27278 Carrboro, NC 27510 Chapel Hill, NC 27514 1/ 4 iQ !Pp1 %� DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT 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 2/9/2017 1:10:02 PM M: i ::I II 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT 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 2/9/2017 1:10:02 PM ::: i ::I 0 ; .8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT 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 2/9/2017 1:10:02 PM M: i i ::I II ;' t;1µ DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A FOR OFFICE USE ONLY PROVIDER'S OUTSIDE AGENCY APPLICATION Received By Date/Time / Agency Orange County Historical Museum Program(s) Heritage Education; Education through Exhibits; Preservation and conservation includes research Section Subsection 1. Cover Page a. x Applicant Contact Information b. x Funding Requests c. x Signed Application Cover Page d. xSianed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. x Agency's Years in operation b. x Agency's Purpose/Mission c. x Agency's Types of Services Provided d. x Agency's Experience with Programs e. ❑ Other Pertinent Agency Information f. x Schedule of Positions g. x Living Wage 3. Program Information a. x Human Services Needs Priority b. x Type of Program A separate Section 3 is c. x Agency Collaboration required for each d. x Summary of Program program. e. x Description of Identified Need f. x Description of Population to be Served g. x Program Staffing, Capacity, & Expertise h. x Program Implementation Timeline i. x Value of Investment j. x Impact of Reduced/No Allocation k. ❑ Other Pertinent Information I. x Target Population/Beneficiary Chart m. x Work Statement n. x Program Budget, Detail, & Cost per Individual Application Submittal Checklist 2/9/2017 1:10:02 PM II: M: a u^ 5 o II 5 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. Attachments a. ❑ Audit: Organizations receiving $300,000 or more in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. x IRS Federal Form 990 c. x NC Solicitation License d. x IRS Federal Tax-Exemption Letter e. x Certificate of Insurance f. x List of Board of Directors Application Submittal Checklist 2/9/2017 1:10:02 PM M:.:: i C 6 (:: 0 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: the Historical Foundation of Hillsborough & Orange County Applicant Organization's Physical Address: 201 North Churton St., Hillsborough, NC 27278 Applicant Organization's Mailing Address: 201 North Churton St., Hillsborough, NC 27278 Applicant Organization's Web Address: www.orangenchistory.org Executive Director: Candace Midgett Telephone Number:_(919) 732-2201 E-Mail: director @orangenchistory.org 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 - County- HS HS Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects Orange County Historical Museum: heritage education; education through exhibits; preservation and conservation (includes $7260.00 $7260.00 research) Totals $7260.00 $7260.00 AGENCY INFORMATION 2/9/2017 1:10:02 PM P :1e 7 o 3 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. M Signature: \ 'IN, 1 e--0)1,A Executive Director Dat r it _ r 1 ." ' ( ` -- `"// , 01/31/2017 Si Hato re ° - Board Chairperson Date 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 ❑ X a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ X 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? ❑ X c) Current beneficiaries of the program for which funds are being requested? ❑ X 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 AGENCY INFORMATION 2/9/2017 1:10:02 PM II:' M:1 y 8 3 :;r II J 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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 qrant awarded. Signature: 'n \ N, 1 e--0)1,A Executive Director Dat / 1/A—, r Si at re: '' ( `---- /Vei'' , 01/31/2017 g Board Chairperson Date AGENCY INFORMATION 2/9/2017 1:10:02 PM P 3 g l" 9 3 0 3 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 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): Orange County Historical Museum, in operation for 58 years, was incorporated in 1983. The Historical Foundation of Hillsborough and Orange County (HFHOC), incorporated in 2007, has operated OCHM for nine years. OCHM is open six days per week, and offers free admission to visitors. b) Agency's Purpose/Mission (no more than a few sentences): Mission of HFHOC: to enlighten and engage our community and visitors from around the world by preserving and interpreting the history of Orange County. c) Types of Services the Agency Provides (bullet format): • Collection. • Preservation. • Cataloging. • Housing historic artifacts and documents relevant to Orange County history. • Using collections as an educational tool: including exhibitions, public program, publications, and special events. • Making OCHM archives/collections available to researchers. • Providing support for historic preservation efforts in Orange County. d) Agency's History with Providing These Services: The museum has extensive experience with programs for which we seek FY17-18 funding: Program 1. Heritage education: 60 years. • Traveling trunks: 15 years. Since 2002 this program (designed to meet NC's essential standards for study) has provided content and lesson plans (updated in 2012) to offsite users. A modest rental fee supports program access for the community. • Outreach: 60 years. In 1957, OCHM hosted its first field trip to a class of 7th graders. Museum staff continues to invest significant development and execution time in heritage education programs, at the museum and as outreach in OC public schools and the OC community. Primary audience: students in grades 1.5. • Hillsborough History Days: 11 years. OCHM, in collaboration with Burwell School and Alliance for historic Hillsborough, presents History Day heritage education to participating K-12 student groups through on-site tours and hands-on activities. Program 2: education through exhibits: 59 years. Since 1958, OCHM has provided public education through temporary and permanent exhibits. From the first exhibits based on Colonial-era English weights and measures and Eno Rive Native American artifacts to a current look at tools of historic OC commerce, industry and government, exhibits inform and support museum visitors' understanding of Orange County history. Program 3: Preservation and conservation: 60 years. • Preservation and conservation: From the Hillsboro Garden Club's 1957 concept of a museum providing substantial protection for the long-treasured artifacts they held, to HFHOC's 2017 mission statement upholding these core values, the museum's Agency Information 2/9/2017 1:10:02 PM ugo 10 If DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT A PROVIDER'S OUTSIDE AGENCY APPLICATION collection has stimulated and encouraged meaningful public engagement with OC history. The process of collection, preservation and conservation of significant cultural artifacts supports the design, interpretations and implementation of exhibits about OC history that continue to educate and delight our visitors. • Access: the museum offers access to its historic documents and other artifacts to those researching Hillsborough and OC history. OCHM staff also provides individualized collections research assistance to support individual and community historical projects. • Historic preservation: OCHM supports preservation efforts in Hillsborough and OC in projects like the 2015 slave Dwelling Project event in Hillsborough promoting the interpretation and preservation of existing slave dwellings across the U.S. 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 has been no change in directorship at OCHM since 2014. We continue to expand our initiative to diversity collections, programs and audience. f) Schedule of Positions (For Entire Agency) • Full Time Equivalent (FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE - Full-Time Paid Positions: 0.75 # of FTE - Paid Part-Time Positions: 0.75 # of Volunteers: 20 # of FTE -Volunteers: 0.6 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes /No) NO If yes, is this agency an Orange County Living Wage Certified Employer? If no, please explain. The museum is operated by HFHOC to fulfill its mission to enlighten and engage the community and visitors from around the world by preserving and interpreting Hillsborough and OC history. Income sources are primarily endowment grants and proceeds from fundraising activities. Wage structure reflects our financial status and is quite similar to other museums in the area. Though lower than current OC living wage targets, OCHM staff wages have steadily increased since 2014. Employment in small museums such as OCHM provides staff with the opportunity to engage with museum practices and obtain skills that allow them to advance in future careers. Employees are able to work in an environment that fosters learning, curiosity and connection with a community of stakeholders who are passionate about the goals and mission of our museum. In balancing the competing needs for wages, operations and program, HFHOC can afford to make small steps toward making living wage salaries for all museum staff a reality. This is a better use of limited resources than offering unpaid internships and reducing paid staff. The HFHOC board has been tasked with the responsibility of making living wage salaries a priority for the museum and is actively seeking funding that would allow this goal to be met within the next several years. Agency Information 2/9/2017 1:10:02 PM rage 11 e If 3 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 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) NO If yes, please list below: Include all programs that have funding requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY16- FY17-18 Source 17 Request Award Ex: Affordable Rental 0 $20,000 Carrboro - Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $15,000 Carrboro — Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate 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 Agency Information 2/9/2017 1:10:02 PM I: uge 12 o If 10 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 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? Yes (Deficit) 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? v. July 1, 2017-June 30, 2018 (Example: July 1, 2016 through June 30, 2017) Agency Information 2/9/2017 1:10:02 PM page 0 If 3 8', DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: Preservation and conservation PROGRAM REVENUE Actual Estimated Projected Percent Change 2015-16 2016-17 2017-18 Private Donations $ 12922 $ 11500 $ 12650 10% Program Generated Revenue $ 0- $ 600 $ 660 10% Local Government Grants: Human Services-Town of Carrboro $ - $ - $ - 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ 6000 $ 6600 $ 7260 0 Other- Orange County $ 1500 $ 1500 $ 1650 10% Other-Town of $ 14000 $9995 $10995 10% Hillsborough Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants Strowd Rose $ 1500 $ 1500 $ 1650 10% Other Revenue $ 29,606 $ 37,750 $ 41,525 10% Total Program $ 65,528 $ 69,445 $ 76,390 10% Revenue PROGRAM EXPENSES Compensation $ 4,524 $ 6371 $ 6371 0 Rent& Utilities $ -- - $ -- - $ -- - --0 Supplies & Equipment (listed $ 300 $ 330 $400 33% under Heritage education) Travel & $ -- - $ -- - $ -- - --0 Training Other Expenses: $ - $ - $ - 0 Total Program Expenses $4824 $6701 $6771 1.04% SURPLUS/(DEFICIT) FOR $ <908> $ 0 $ 0 $ 0 PERIOD: DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: Heritage education PROGRAM REVENUE Actual Estimated Projected Percent Change 2015-16 2016-17 2017-18 Private Donations $ 12,922 $ 11,500 $ 12,650 10% Program Generated Revenue $ - $ 600 $ 660 10% Local Government Grants: Human Services-Town of Carrboro $ - $ - $ - 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ 6000 $ 6600 $ 7260 10% Other- Orange County $ 1500 $ 1500 $ 1650 10% Other-Town of $ 14,000 $ 9995 $ 10995 10% Hillsborough Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants Strowd Rose $ - $ 1500 $ 1650 10% Other Revenue $ 29606 $ 37750 $ 41525 10% Total Program $ 65,528 $ 69,445 $ 76,390 10% Revenue PROGRAM EXPENSES Compensation $4807- $5423 $5423 0 Rent& Utilities $ -- - $ -- - $ -- - 0 Supplies & Equipment $600 - $660- $725 9.8% Travel & $200 - $188 $188 0 Training Other Expenses: $ -- $ -- - $ ---- 0 Total Program Expenses $5607 $6271 $6336 1% SURPLUS/(DEFICIT) FOR $ <908> 0 0 0 PERIOD: DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: Education through exhibits PROGRAM REVENUE Actual Estimated Projected Percent Change 2015-16 2016-17 2017-18 Private Donations $ 12,922 $ 11,500 $ 12,650 10% Program Generated Revenue $ - $ 600 $ 660 10% Local Government Grants: Human Services-Town of Carrboro $ - $ - $ - 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services- Orange County $ 6000 $ 6600 $ 7260 10% Other- Orange County $ 1500 $ 1500 $ 1650 10% Other-Town of $ 14000 $ 9995 $ 10995 10% Hillsborou•h - - Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants Strowd Rose $ $ 1500 $ 1650 4% Other Revenue $ 29,606 $ 37,750 $ 41,525 10% Total Program $ 64,028 $ 69,445 $ 76,390 10% Revenue PROGRAM EXPENSES Compensation $ 16,941 19,771 19,771 --0 Rent& Utilities $ -- - $ -- - $ -- - --0 Supplies & Equipment $ 600 $660 $750 0 Travel & $ -- - $ -- - $ -- - --0 Training Other Expenses: $ -- - $ -- - $ -- - --0 Total Program Expenses $ 17,541 $ 20,431 20,521 4.4% SURPLUS/(DEFICIT) FOR $ <908> $ 0 $ 0 0 PERIOD: DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Heritage education Program Primary Contact and Title: Candace Midgett, executive director Telephone Number: (919) 732-2201 E-Mail: director @orangenchistory.org • Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents X 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 • 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 X X X X Family Resources Jobs/Jobs Training Food Transportation Other: Please specify • 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. • For Hillsborough History Day field trips we work with The Alliance for Historic Hillsborough and Burwell School. • For family workshops like Revollut8inary War Living History ay, we collaborate with The Alliance for Historic Hillsborough. • For Last Friday Art Walk family workshop events we work with the Hillsborough Arts Council. PROGRAM INFORMATION 2/9/2017 1:10:02 PM ; g i 'i a 3 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • For Fairview Art in the Park/Art by the Park out of school time programming, developed and delivered by OCHM and held weekly in the Fairview community, we work with the Hillsborough Police Department and Fairview Community Watch. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: • Summarize the program services proposed and how the program will address a Town/County priority/goal? Heritage education program components: Traveling trunks: each trunk is designed to offer a complete interactive experience illustrated with reproduction artifacts and informed by a detailed lesson plan supporting NC's essential standards for elementary students. A modest rental fee for the program insures it is accessible for a broad range of community users. Outreach: since our first field trip in 1957, OCHM has invested significant staff time in developing and executing heritage education programs, both at the museum and as outreach in OC public schools. The primary audience for museum heritage outreach in OC schools is elementary school students, grades one through five. Field trips offer museum tours with emphasis on our exhibits and hands-on activities for students based on exhibit themes, and created to help anchor the learning experience. Fairview Art by the park/in the Park: This programming provides a learning experience for children from at-risk and low-income households. It is an out-of- school-time arts/crafts activity held weekly at Rainey substation or Fairview Pak in Hillsborough, depending on the season). The program allows children the opportunity to experience a wide array of art media in projects informed by Hillsborough's thriving artist community and the natural world around them. Children in the program range in age from four years to 18 years of age. Hillsborough History Day: For the past 10 years, OCHM, along with Burwell School and the Alliance for Historic Hillsborough to present History Fun Day heritage education. The museum presents tours and hands-on activities to participating K-12 student groups. Tours based on the history of Hillsborough and Orange County are written and delivered to support and enrich OC K-12 students' social studies learning. Special events: OCHM supports the Alliance of Hillsborough's Living History days with programs and activities designed for families with children. These include revolutionary War Living History Day, Hillsborough Day, and Hillsborough Fourth of July events. We offer workshops and demonstrations designed to highlight Hillsborough's rich history. For example, for this year's Revolutionary War Living History Day, we will present a spinning/weaving workshop highlighting the history of domestic textile production with an in-gallery demonstration spinning/weaving demonstration by local artisan Anna Currie and a hands-on family weaving workshop. PROGRAM INFORMATION 2/9/2017 1:10:02 PM rage 1 e If DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • 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 goals, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. In published goals/priorities reports, OCBOC and town of Chapel Hill have included the goal of providing educational opportunities and recreational activities for children and families. The town of Chapel Hill, I particular, indicates the lack of sufficient low-cost or free activities for children, youth, and LEP students. All of OCHM's exhibits and events are consciously designed to be inclusive of all members of the diverse OC community we serve. Attendance at OCHM for field trips, special tours for students, family workshops and exhibits, and participation at Fairview Art/park programs are available at no cost to participants. Traveling Trunk program fees have a price scale ($10 for a two week rental) intended to be accessible to all community groups. Perhaps most important in meeting town/county priorities is the role our museum can play in fostering a desire in students to become actively engaged in their community. The OC Board of Commissioners, in particular, has included the goal of full civic participation in our community in their goals/priorities for the future. Here's what Christopher T. Gates, president of PACE (Philanthropy for Active Civil Engagement) has to say about how museums play a role in fostering and sustaining civic participation: By providing the means to preserve memory, sustain culture, and create identity, museums help equip us to understand each other and ourselves. And it is this understanding that animates our efforts to strengthen democracy, promote civic engagement, and build community. • Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Heritage education targets K-12 students. They are reached via correspondence and social media directed to educators. Traveling Trunk program users self-identify as interested learners. They come primarily from church and home school groups, and community youth organizations. Special events participants are reached through social media, word of mouth and printed and distributed advertising. They are identified and connected through their interest in community resources, specifically cultural activities for families. • Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Resume for the Executive Director (project manager) and Museum Coordinator are attached. Museum volunteers prepare materials for hands-on activities, but do not participate in delivery of workshops or lesson plans. PROGRAM INFORMATION 2/9/2017 1:10:02 PM IP' ° t 6 e If 3 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION The executive director, in consultation with the HFHOC board of directors: • Acts as program director to plan and execute field trip and school outreach lesson plans, including hands-on activities, that support students' in-class studies and support NC's educational essential standards; • Develops and delivers the majority of family workshops; • Develops and delivers weekly Fairview programming. Describe the specific period over which the activities will be carried out and include an implementation timeline. Specific period: July 1, 2017-June 30, 2018. Implementation timeline: commencing July 1, 2017 and continuing through June 30, 2018, OCHM will: • Participate in heritage education programs with The Alliance for Historic Hillsborough and Burwell School on Hillsborough History Days; • Create and deliver on-site field trip experiences for K-12 OC students; • Make traveling trunks available to community groups requesting them; • Deliver weekly arts/crafts programming to the Fairview community. 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) Students who experience OCHM outreach through classroom visits and field trips to the museum aren't just learning about history. • They learn about other cultures in a way that fosters understanding and, along with it, respect and tolerance for those different from ourselves; • They experience the joy of learning through observation, inquiry, and the exercise of imagination; • They learn that fallible humans interpret and record history, thus making it an evolving narrative requiring more of learners than passive acceptance. • In this process they learn about themselves, their place in the world, and the importance of their own story. They recognize the importance of connecting with the stories of others—which fosters in them a beginning awareness of the importance of community in the life of its members. • Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If we do not receive requested funding or receive a reduced allocation of funding, OCHM would be forced to lessen the amount of outreach we do to the community, and to assess which programs to cut in order to continue critical heritage education programming. • Include any other pertinent information. PROGRAM INFORMATION 2/9/2017 1:10:02 PM I ' ° I / If DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information: Heritage Education • 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 Projec- 2015-16 2016-17 ted 2017-18 Gender Male 1023 1250 1300 Female 1024 1250 1300 Total 20470 2500 2600 Ethnicity African-American 325 425 4420 American Indian or Alaska Native Asian Caucasian 1250 1400 1456 Native Hawaiian or other Pacific Islander Other: specify 472 675 702 Total 2047 2500 2600 Of the above, how many Hispanic/Latino 372 425 445 Of the above, how many non-Hispanic/Latino 1675 2075 2158 Total 20470 2500 2600 Age 0-5 years 6-18 years 2047 2500 2600 19-50 years 51+ years Total 20470 2500 2600 Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown (?)no Chapel Hill Public Housing (?)no data (?)no data data Town of Chapel Hill (Non-Public Housing) 473 650 650 Town of Carrboro 78 75 75 Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) 1496 1775 1775 Total 2047 2500 2600 PROGRAM INFORMATION 2/9/2017 1:10:02 PM : I 8 o If DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement • 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.) PROGRAM INFORMATION 2/9/2017 1:10:02 PM Page 19 90 f 8, DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement Chart for Program Heritage Education 1. Program Activity Heritage education: traveling trunks; outreach; Fairview Name Art/Park; Hillsborough History Day; special events. Program Goal Deliver programming to 2600 OC school age children and families Performance Measures Will track the number of students served Previous Year Program 2015 result of 2500 students served was lower than Results estimated at 2047, due to water damage/museum closure. Current Year Estimated 2500 students served Results Next Year Projected 2600 students served Results 2. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 3. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PROGRAM INFORMATION 2/9/2017 1:10:02 PM Page 0 o If 3 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • 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? 8.3% PROGRAM INFORMATION 2/9/2017 1:10:02 PM Page 1 o If 3 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015- Estimated 2016- Projected 2017 16 17 18 Total Cost of Program $5607 $6271 $6336 Total # of Individuals 2047 2500 2600 Cost Per Individual $2.74 $2.51 $2.44 PROGRAM INFORMATION 2/9/2017 1:10:02 PM If DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Education through exhibits Program Primary Contact and Title: Candace Midgett, executive director Telephone Number: (919) 732-2201 E-Mail: director @orangenchistory.org • Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents X 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 • 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 X X X X Family Resources Jobs/Jobs Training Food Transportation Other: Please specify • 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. • OCHM collaborates frequently with Free Spirit Freedom, an OC cultural arts initiative promoting and supporting events and exhibits highlighting ethnic and social aspects of the culture and history of African-American, Native American and other traditionally marginalized communities. For example in February 2017 OCHM will install an exhibition, 'Horace Johnson and the History of Hillsborough', highlighting the political career of H:illsborough's first African-American mayor. The exhibition runs in conjunction with a FSF event, 'Horace Johnson Day', commemorating Mr. Johnson's life and career. • In the month of December OCHM installs and exhibits student entries in the Orange County Schools Annual Art Competition. 2016 was the second year of the event, and we anticipate that it will be an annual tradition. PROGRAM INFORMATION 2/9/2017 1:10:02 PM p : q 2 2 u If 3 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: • Summarize the program services proposed and how the program will address a Town/County priority/goal? Collections are the core of any museum. From collections e build exhibits that help to inform learning about the history of Orange County for a diverse audience, from K-12 students to members of a Memory Café for senior citizens. Our collection helps contextualize relevant contemporary issues in the community in the perspective of historical knowledge, and to foster a broad and inclusive dialogue based on that deeper and richer understanding. Temporary exhibitions help keep OCHM a vital and changing experience for visitors; permanent exhibits of long-treasured objects that are part of town and county identity, like weights and measures, bring visitors here again and again to see old friends with fresh eyes, and to once again learn something new in the process. The process of exhibition conceptualization, design, installation and education allows museum staff to give voice to members of our community perhaps seldom heard, and to reanimate objects in the light of contemporary experience. • 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 goals, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. Priorities/goals for both OCBOC and the town of Chapel Hill speak to the need for more educational opportunities for adults committed to lifelong learning, and choices for families looking for quality recreational experiences. OCHM acts as a community resource providing these opportunities and experiences at no cost, in an environment that promotes and fosters diversity, and where education and recreation combine to give visitors a rich learning environment • Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Our target population is comprised of people likely to visit museums from around Orange County and the world, people interested in the subjects touched on by our exhibits, and people seeking educational and recreational opportunities. Our outreach to visitors includes social media, county public venues (web-based community calendars, for example) printed advertising materials, word of mouth, local news coverage and OCHM participation at a variety of special county events. Many of our visitors self-identify as being interested in museums and seek us out; others are reached through the methods described above. Exhibits are designed to appeal to visitors with varied interests, backgrounds, and education levels, and to engage and encourage their patronage of the museum. • Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Resumes for the director and museum coordinator are attached. Our volunteers do not participate in exhibit planning or gallery tours. PROGRAM INFORMATION 2/9/2017 1:10:02 PM 0 , age 80 38 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION The executive director, in consultation with the HFHOC board of directors, acts as program director in planning and executing temporary and permanent exhibits, utilizing museum collections and collections offered for temporary loans by community members. The executive director also delivers the majority of exhibit tours and develops special events to support exhibits. The museum coordinator works on social media and printed publicity to support exhibits and related events, and also helps deliver visitor tours. • Describe the specific period over which the activities will be carried out and include an implementation timeline. • OCHM maintains a perpetual calendar of permanent and temporary exhibits throughout the year. From July 1, 2017-June 30, 2018, we will be engaged in displaying permanent exhibitions and developing temporary exhibitions for our community of museum visitors. • 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) • Investing in OCHM assures that there will be a place for representation of accurate, inclusive, historical interpretation accessible and available to all OC citizens. It assures there will be a place where all who wish to take advantage of the rich learning opportunities museums offer can do so. OCHM is a space where visitors are offered the foundation of good citizenship in our democratic society: a working knowledge of history and its impact on contemporary issues, one that not only broadens our knowledge, but expands our world view in the process. Paleontologist and passionate museum advocate Stephen Jay Gould said this: `Nothing is more dangerous than a dogmatic worldview—nothing more constraining, more blinding to innovation, more destructive of openness in novelty.' A vital OCHM will enlighten, entertain, and open the imagination of our visitors and our community, if we continue to receive the funding we seek. • Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. OCHM staff would have to make difficult decisions about which exhibits to develop, and which to abandon, if we do not receive the full funding we request. The opportunity to develop some exhibitions for the purpose of engaging, educating, and delighting visitors with narratives illustrated and enriched by artifacts from our collections would be lost. • Include any other pertinent information. PROGRAM INFORMATION 2/9/2017 1:10:02 PM nage o If 38 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information: Education through Exhibits • 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 2713 4500 4000 Female 2714 4500 4000 Total 5427 9000 8000 Ethnicity African-American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Total 0 0 0 Of the above, how many Hispanic/Latino Of the above, how many non-Hispanic/Latino Total 0 0 0 Age 0-5 years 6-18 years 19-50 years 51+ years Total 0 0 0 Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non-Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) Total 5427* 9000* 8000* PROGRAM INFORMATION 2/9/2017 1:10:02 PM F' a g o 2 6 of 3 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION *Note: OCHM does not capture statistics on gender, ethnicity or age from program participants or museum visitors. Work Statement • 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 Pro•ram: Education Through Exhibits 5. Program Activity Name Educating through exhibits Program Goal Deliver exhibit programming to 8000 visitors Performance Measures Will track the number of museum visitors Previous Year Program Results 2015: 5427 visitors served, due to flooding/building closure. Current Year Estimated Results Deliver exhibit programming to 9000 visitors Next Year Projected Results Deliver exhibit programming to 8000 visitors 6. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 7. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 8. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results • Program Budget PROGRAM INFORMATION 2/9/2017 1:10:02 PM nage 2 "'1 0 If 38 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 5. 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 6. Program Budget Detail — Provide description of "other" budget items, not defined. 7. This program budget represents what percent of the agency budget? 27% 8. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program $17,541 $20,431 $20,521 Total # of Individuals 5435 9000 8000 Cost Per Individual $3.23 $2.27 $2.57 PROGRAM INFORMATION 2/9/2017 1:10:02 PM I' g 8 e 3 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Preservation and conservation Program Primary Contact and Title: Candace Midgett, executive director Telephone Number: (919) 732-2201 E-Mail: director @orangenchistory.org • Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents X 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 • 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 X X X X Family Resources Jobs/Jobs Training Food Transportation Other: Please specify • 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. • Program Description (3 pages OR LESS) Please provide the following information about the proposed program: PROGRAM INFORMATION 2/9/2017 1:10:02 PM 1 o 2 9 If 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Summarize the program services proposed and how the program will address a Town/County priority/goal? Preservation and collection: The museum's collection, preserved and shared in our archives and galleries, continues to be a powerful tool for engagement in Orange County history by our community through educational and recreational opportunities. These high quality, no cost programs are the experiences that both the town of Chapel Hill and the OC BOC are eager to offer their community members. Without continued collection and preservation efforts, the museum's ability to teach, exhibit and inform our community would be significantly restricted. Research: The museum offers access to its collection documents for those researching Hillsborough and Orange County history, both individual and community projects. OCHM provides research opportunities to the community, including access to archival and acquisition files. Museum staff offers researchers assistance with specific requests and shares any information held in the museum collections. Staff also offer resources, including referrals in the community, to other organizations that may have information relevant to individuals' projects. • 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 goals, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. OCHM's ability to fulfill town of Chapel Hill and OCBOC needs expressed in relation to the museum's mission and goals, including provision of learning and recreational opportunities, are predicated on the successful preservation and conservation of the collections we hold. All museum activities, projects, and programs, are pegged to our mission and mandate to collect, preserve protect, and share those artifacts that tell the story of Orange County's diverse, deep and rich history. • Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? All museum visitors, as described in OCHM's heritage education and education through exhibits programming, are served by OCHM's preservation and collection mission. They are identified and reached through the venues described for each program above. PROGRAM INFORMATION 2/9/2017 1:10:02 PM I ' : If DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION The museum's research program benefits both professional and amateur researchers seeking specific information from OCHM about historic Orange County events and people. They are a self-identifying group and make direct contact with OCHM in their search for information. • Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Resumes for the executive director and museum coordinator are attached. The executive director, acting as project manager, is directly responsible for OCHM's preservation and conservation policies and practices. The HFHOC board is responsible for all acquisition decisions. Initial review of artifacts is made by a special collections committee, of which the executive director is a member. Any final decision about artifact accession is made by the full HFHOC board. • Describe the specific period over which the activities will be carried out and include an implementation timeline. Implementation: July 1, 2017-June 30, 2018. Our preservation and conservation activities are a part of daily routine in a perpetual cycle of caring for our collection. Collections activities are ongoing throughout the year, as OCHM staff responds promptly to community offers of donations. • 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) In order for OCHM to provide heritage education, educate through exhibits, and allow access to archival collections, we must have a collection that is properly preserved and conserved. The core mission of the museum is, and has been since 1957, to provide protection and care for treasured artifacts held in our collections for the enjoyment and education of the OC community and visitors around the world who come to visit OCHM. • Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Reduced funding for this core mission would mean that OCHM would seek to accession fewer artifacts, and have a reduced ability to prepare other artifacts for display, and diminish not only our ability to provide appropriate care for our collections, but also the ability to share our collections with visitors. • Include any other pertinent information. PROGRAM INFORMATION 2/9/2017 1:10:02 PM g e If 3 8 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information: Preservation and Conservation • 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 17 15 15 Female 18 15 15 Total 35 30 30 Ethnicity African-American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Total 0 0 0 Of the above, how many Hispanic/Latino Of the above, how many non-Hispanic/Latino Total 0 0 0 Age 0-5 years 6-18 years 19-50 years 51+ years Total 0 0 0 Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non-Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) Total 35* 30* 30* PROGRAM INFORMATION 2/9/2017 1:10:02 PM Page 32 o If 3 , DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION *Note: OCHM does not capture statistics on gender, ethnicity, or age from program participants or individual researchers. Work Statement • 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.) PROGRAM INFORMATION 2/9/2017 1:10:02 PM I' : e 3 :"'l o If 3 i, DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement Chart for Program Preservation and Conservation 9. Program Activity Provide information upon request for individual and Name community research projects Program Goal Complete research projects for those requesting assistance from OCHM Performance Measures Number of research projects completed Previous Year Program 2015: 35 research projects completed Results Current Year Estimated 30 research projects completed Results Next Year Projected 30 research projects completed Results 10.Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 11.Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 12.Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PROGRAM INFORMATION 2/9/2017 1:10:02 PM Pagell o If 3 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Program Budget 9. 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 10.Program Budget Detail — Provide description of "other" budget items, not defined. 11.This program budget represents what percent of the agency budget? 8.9% PROGRAM INFORMATION 2/9/2017 1:10:02 PM Page 35 o If 3 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 12.COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2015- Estimated 2016- Projected 2017- 16 17 18 Total Cost of Program $4824 $6371 $6371 Total # of Individuals 35 30 30 Cost Per Individual $137.83 $212.37 $212.37 PROGRAM INFORMATION 2/9/2017 1:10:02 PM "1 6 II 11 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHI BIT 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 2/9/2017 1:10:02 PM olugo e0 f DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 XHIBIT 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 2/9/2017 1:10:02 PM ug c o0 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 EXHIBIT "B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Historical Foundation of Hillsborough& Orange County Program Name: Education through exhibits Funding Award: $6699 Outline how the agency will spend Orange County's funding award. Expense Description Amount Executive director salary $19,771 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Develop temporary and permanent museum exhibitions throughout the year based on accurate, inclusive historical interpretation of OC history through use of artifacts from OCHM permanent collections and other artifacts loaned from community members. • Exhibit a perpetual calendar of permanent and temporary exhibits throughout the year. • Develop educational tours and special events to support museum exhibits. • 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 Deliver exhibit programming to visitors 8000 Measure by tracking number of museum visitors DocuSigned by: Executive Director, OCHM 9/25/2017 939: 61 + . Certified by _,;i, ,\ i355F Title: elY(%C j\-,,;-Q,� 6 k:A Ok Date: 1' L,--1, c=z (Provider's Sign ili re) DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 EXHIBIT "B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Historical Foundation of Hillsborough& Orange County Program Name: Heritage education Funding Award: $6699 Outline how the agency will spend Orange County's funding award. Expense Description Amount Executive director salary $5423.00 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Curate and distribute heritage education traveling trunks to OC public and private schools, and other community groups; • Deliver programming to 2600 OC school age children and families, both in schools and at OCHM, through classroom visits, participation n Hillsborough History Days and through a museum field trip program; • Deliver programming to weekly Fairview Art in the Park participants, and through other special educational events/activities. 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 Deliver history educational programming to 2600 OC school children and families 2600 students Measure performance through number of students served DocuSigned by: ✓t,vl,VJ -W � Executive Dairector, OCHM 9/2 /2017 4 .,5:1w,.5F... y Certified by `�... '3 . �, +� Title:E-`7C; c ! C -A,c5` ' Date:2 Ada (Provider's S'_nature) 1 DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 EXHIBIT "B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Historical Foundation of Hillsborough& Orange County Program Name: Preservation and conservation Funding Award: $6699 Outline how the agency will spend Orange County's funding award. Expense Description Amount Executive director salary $6371 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Provide preservation and conservation to all OCHM collections through a daily routine of care based in best museum practices; • Respond to community offers of donations through execution of HFHOC collections policies governing artifact acquisition and deaccession; • Provide information upon request for individual and community research projects by completing research projects for those requesting assistance from OCHM. 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 30 complete Complete research projects for those requesting assistance from OCHM projects Measure performance through tabulation of research projects completed ..........DuLu lgneu uy: 4 44 Certified b '. ? Title: 74,'c t t 'c,. _ Date:2_,L-- \,,,A._ ' ' ,„ ,... (Pro''der's _ ature) d DocuSign Envelope ID:80528E57-64B2-4BCE-A558-776533408604 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: �/f Oaf-.w- 9/25/2017 Certified by: Title: Executive Director, OCHM Date: 7dQ'�QR'�FR1 flftdFF (Provider's Signature) (Historical Foundation of Hillsborough and Orange County) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSi n Envelope ID:80528E57-64B2-4BCE-A558-776533408604 F� Erie CERTIFICATE OF INSURANCE DATE ISSUED(MM/DD/>'1') Insurance® -THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY— 7/12/17 Home Office • 100 Erie Insurance Place • Erie,Pennsylvania 16530 • 814.870.2000 Toll free 1.800.458.0811 • Fax 814 870.3126 • www.erieinsurance.com NAME AND ADDRESS OF AGENCY THE BALLARD AGENCY AGENT'S NO. INSUhA I GU RUG COVERAGF JJ1010 _Co.:C ERIE INSUh I\Gt GU f'A Y 105 W KING ST Co.:D ERIE INSURANCE PROPERTY_&CA SUALTY COM AN HILLSBOROUGH,NC 27278-2543 Co.:E ERIE INSURANCE EXCHANGE, Not App'cal le Erie Indemnity Co.,Attorney-In-Fact k inNY__ Co.:F ERIE INSURANCE COMPANY OF NEW YORK (919)732 2158 Co.:G FLAGSHIP CITY INSURANCE COMPANY This certificate is issued for information purposes only and conf'•rs NAME AND ADDRESS OF NAMED INSURED no rights on the certificate holder. It does not affirmatively or negatively amend,extend,or otherwise alter the terms,exclusions HISTORIC HILLSBOROUGH and conditions of insurance coverage contained in the policy(ies) COMMISSION indicated below.The terms and conditions of the policy(ies)govern the insurance coverage as applied to any given situation.Li its PO BOX 922 shown may have been reduced by claims paid.This certificate",of insurance does not constitute a contract between the issu ng HILLSBOROUGH,NC 27278 insurer(s), authorized representative or producer and he certificate holder. This is to certify that policies,as indicated by the Policy Number below,are in force for the Named Insured at the time that the Certificate is being issued. 1 [(��11 ��11►1 �1 tq�y ` TR nsad TYPE OF INSURANCE ;,POLICY NUMBER r,h,'Nei 14 �I N ,'i f iii LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any One Fire) $ ❑ CLAIMS MADE ❑ OCCUR MED EXP(Any One Person) $ ❑ PERSONAL&ADV.INJURY $ ❑ GENERAL AGGREGATE $ GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG$ ❑POUCY I I PROJECT ❑LOC I AUTOMOBILE LIABILITY BODILY INJURY ❑ "ANY AUTO"(ON ODI,H D), (EACH PERSON) $ 11 OWNED BODILY INJURY (EACH ACCIDENT) $ ❑ HIRED PROPERTY DAMAGE $ I I NON-OWNED BODILY INJURY AND PROPERTY DAMAGE El GARAGE COMBINED $ I 1 EXCESS LIABILITY EACH OCCURRENCE $ ❑ OCCURRENCE AGGREGATE $ ❑ RETENTION $ $ E WORKERS COMPENSATION& STATUTORY EMPLOYERS LIABILITY Q86 0600392 2/6/17 2/6/18 ACCIDENT $ 500,000 EACH ACCIDENT BODILY INJURY DISEASE $ 500,000 POLICY LIMIT BY DISEASE $ 500,000 EACH EMPLOYEE OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIV- ERED IN ACCORDANCE WITH THE POLICY PROVISIONS. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). NAME AND ADDRESS OF CERTIFICATE HOLDER ORANGE COUNTY AUTHORIZED REPRESENTATIVE PO BOX 8181 HILLSBOROUGH,NC 27278 601,0/.1v41 EIG6230 8/11 Pane 1 of 1