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2017-584-E Finance - Orange Congregations in Mission - Outside Agency Performance Agreement
DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2017, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and Orange Congregations in Mission, a not-for-profit corporation, located at 300 Millstone Drive, 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 Orange Congregations in Mission agree as follows: 1. Term of the Agreement. The tenn of this Agreement shall be a program year beginning July 1, 2017 to June 30,2018. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 71415 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 17853.75. 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. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Orange Congregations in Mission) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 - June 30. Reports are due on January 12, April 13, and July 13 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services,upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default"), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider,the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten(10)business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (Orange Congregations in Mission) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers'or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A- Statutory State NC & Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (Orange Congregations in Mission) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves,their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.75 per hour. To the extent possible, Orange County recommends that Orange Congregations in Mission provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (Orange Congregations in Mission) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 County: Finance &Administrative Services Provider: Orange Congregations in Mission Orange County 300 Millstone Drive Post Office Box 8181 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. 7 Fo RikeligIbehalf of the Provider .. SUAVA& S. FVt,tl,an,d, 10/11/2017 BE62EC6D675A483 , Date (Orange Congregations in Mission) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 7 ne#t�zlf of Orange County Government For NIAA/ut, tk'GUMwtt,V'Stt,i 10/23/2017 f1637QA4R755F477 Bonnie Hammersley, County Manager Date (Orange Congregations in Mission) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency Orange Congregations In Mission Received By Program(s) Meals on Wheels Date/Time Samaritan Relief Ministry - Section Subsection 1. Cover Page a. El/Applicant Contact Information b. Er-Funding Requests c. E1 Signed Application Cover Page d. ,[2igned Disclosure of Conflicts of Interest and Clause 2. Agency Information a. Agency's Years in operation b. E Agency's Purpose/Mission c. 171 Agency's Types of Services Provided d. II Agency's Experience with Programs e. n Other Pertinent Agency Information f. II Schedule of Positions g. 0Living Wage h. [El Agency Budget 3. Program Information a. Human Services Needs Priority b. EjTypeofProgram A separate Section 3 is C. El Agency Collaboration required for each program. d. Er Summary of Program e. 0 Description of Identified Need f. ET Description of Population to be Served g. 0 Program Staffing, Capacity, & Expertise h. 0 Program Implementation Timeline 1. EIF Value of Investment j. El Impact of Reduced/No Allocation k. E Other Pertinent Information L L.,,r Target Population/Beneficiary Chart m. 0Work Statement n. IN Program Budget, Detail, &Cost per Individual 4. Attachments a. Et-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. 0-iRS Federal Form 990 c. NC Solicitation License d. 0"IRS Federal Tax-Exemption Letter e. 0tertificate of Insurance f. gList of Board of Directors g. 0 Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 1/30/2017 10:05:20 AM P a 5 t 2 3 DocuSign Envelope ID 71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 EXHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Orange Congregations In Mission, Inc. Applicant Organization's Physical Address: 300 Millstone Drive, Hillsborough, NC 27278 Applicant Organization's Mailing Address:300 Millstone Drive, Hillsborough, NC 27278 Applicant Organization's Web Address:www.ocimnc.orq Executive Director: (Rev.) Sharon S. Freeland Telephone Number: 919-732-6194 E-IVIail:ocimsrm( Rmbargmail.com Tax ID Number: b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested— For AO Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total -HS Hill-HS Count -HS Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials foryouth activities and projects Meals on Wheels 17,000 17,000 Food purchases Meals on Wheels 17,000 17,000 Expansion and utilization of Cedar Grove Community Center part time employee salary and mileage Samaritan Relief Ministry 58,415 58,415 Food, rent/utility assistance,program manager salay_ — Totals 92,415 92,415 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 n 1411)'';1,,eit '4 ..L-,(// Signature: l , -,,_ ■. , &e,e__-, j 1 2,,,)I 11 Executive Director Date ' Signature: —"v (;) )11,--edvievl--) 1 e oa - rd Chair-person Date i 1 2,01 --1 AGENCY INFORMATION 1/30/2017 4:48:17 PM I. i) ,7 3 fJ (, ' 2 3 , 1 j1, i i i4 0 //;i' 1%, 1 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION c) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AN' NON DISCRIML ATION 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 LI X a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? El 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? c) Current beneficiaries of the program for which funds are being requested? L] 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 exslanation below. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parries nerero for rnemseives, mew agents, =oafs, 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 reverence to any activities carried out by tne grantee, no matter now remote. I ne parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination eoricy. 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 y knowledge and belief 11 of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature:(legy.) ,1-4,1497, p p,21) 1 / E cutive Director Date Signature: i Board Chairperson Date AGENCY INFORMATION 1/28/2017 11:12:49 AM Page 8 o 1 23 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 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): May 1981 b) Agency's Purpose/Mission (no more than a few sentences): To minister to the urgent needs of citizens of northern Orange County through the volunteer efforts of diverse congregations and individuals inspired by faith in God, and to enhance self-sufficiency and awareness of community resources. c) Types of Services the Agency Provides (bullet format): • Meals on Wheels: Provides a nutritious meal, Monday through Friday to primarily elderly people who are homeboun , alone during lunchtime, and unable to prepare a nutritious meal themselves due to either cognitive or physical disability. • Samaritan Relief Ministry: Provides emergency foo s, utility and rental payment, and prescription medication payment. • Thrift Shop: A place where clothing, books, and household items can be purchased for very low cost and donors are able to make tax deductable donations. d) Agency's History with Providing These Services: OCIM's Meals on Wheels program began in September of 1981. At that time the program was strictly volunteer run. In October 2001, OCIM hired the first part-time Meals on Wheels Coordinator. The current Meals on Wheels Coordinator has been with the program for 11 years. The Samaritan Relief Ministry, originally called the OCIM loan program, began with a check book that was kept by the secretary at the First :aptist Church in Hillsborough. The food pantry and Samaritan Relief Ministry office opened in the mid-1980's. The current program manager has been with the program for 19 years. The current Executive Director has been with OCIM for 26 years. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director?Are there new initiatives?) -A new initiative is being considered to utilize the Cedar Grove Comm pity Center for Meal on Wheels distribution to the Cedar Grove and Little River communities. -OCIM uses a certified public accountant to compile its financials each month. -The Hillsborough Storm Water Fee of$600 was unexpected and unbudgeted. It was a hardship to an already stressed budget. ArrPnrii Infnrmafinn 1/ fl/W.)17 4.4R-17 PM P n 1 9 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION f) Schedule of Positions (For Entire Agency) • Full Time Equivalent(FTE) staff will be noted as 1.00;half time as.50;quarter time as.25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE Full-Time Paid Positions: 4 # of FTE - Paid Part-Time Positions: 2.50 # of Volunteers: 85 # of FTE -Volunteers:5 g) Living Wage Does this agency pay permanent employees a minimum . •e? (Yes/No) yes If yes, is this agency an 1:?). g unt Li .0 * I , • e C 0 E 001 .,mr? no If no, please explain. Anonrni Infnrmatinn i/Inoni 7 44R.17 PM P r; I fl r f 2 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 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 FY16-17 FY17-18 Source Award Request 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 NA *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other(DO NOT include CDBG funding here) Artg,nry Infrwmatinn 1/21/7()17 F?-.TR-7 LIM P CY 1 1 n f 9 ,"1 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • 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? deficit Is there a significant change? Yes/No no Please provide a brief explanation for Surplus or Deficit, and significant changes. As of the 1/31/17 deadline, OCIM has not received the audited December 2016 financial report from the accountants. Until the report is available, it will be unclear as to whether there is a deficit or how much it may be. OCIM always operates with a very narrow margin. The shown budget for 2018 is only a mirror of the 2017 budget, with the addition of additional funds OCIM is seeking for Meals on Wheels. The OCIM Board of Directors will begin working on the 2018 budget later this year. iv. What is your agency's fiscal year? January 1, 2017 through December 31, 2017 (Example: July 1, 2016 through June 30, 2017) Anpnrit InfnrmAtinn 1m/21117 4.dR-17 PM P 4 n 1 9 n F 2 ",1 DocuSign Envelope ID:71415AD7-D o�4C��9A9-F93F7208DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Orange Congregations In Mission Combined Budget ~ REVENUE Account Title 2016 Actual 2017 Approved Budget 2018 Contributions $ 86,655.44 $120,156.00 $ 120,156.00 United Way $ 59,195.90 $ 33,161.00 $ 33,161.00 Fuel-Duke Energy Share the Warmth $ 8,652.27 $ 9,800.00 $ 9,000.00 Water Assist.Grant-Hillsborough $ 6,233.95 $ 5,600.00 $ 5,600.00 Food Contributions-Cash $ 22,373.92 $ 19,000.00 $ 19,000.00 Food Contributions-Non-Cash $348,534.O8 $330,000.00 $ 330,000.00 Local Grants (Orange County) $ 50'416.00 $ 50,415.00 $ 9I,415.00 Other Grants $ 63,870.09 $101,500.00 $ 101,500.00 Membership Assessments $ 34,477.75 $ 35,000.00 $ 35,000.00 Recycling Revenue $ 3,481.40 $ 4,088.00 $ 4,000.00 Thrift Shop Sales $144,4I9.45 $148,000.00 $ 148,000.00 Fundraising $ I7,165.17 $ 34,000.00 $ 34,000.00 Walk for Hunger $ 9,6I1.58 $ 14,000.00 $ 14,000.00 Client Fees $ 6,079.80 $ 6,000.80 $ 6,000.00 FEMA $ 13,246.00 $ 15,000.00 $ 15,000.00 Interest Income $ 336.57 $ 500.00 $ 500.00 $874,749.37 $925,332.00 $ 967,332.00 Orange Congregations In Mission Combined Budget EXPENSES Account Title 2016 Actual 2017 Approved Budget 2018 Salaries $221,478.99 $245,008.00 $ 259,400.00 . Benefits $ 36,653.89 $ 38,000.00 $ 38,000.00 Retirement $ 5,151.39 $ 5,000.00 $ 5,000.00 Payroll Taxes $ 13,232.45 $ 18,745.00 $ 18L745.00 Group Insurance $ 31,967.16 $ 35,775.00 $ 35,775.00 Accounting Fees $ 38,625.00 $ 38,000.00 $ 38,000.00 Utilities $ 9,023.39 $ 9'000.00 $ 9,000.00 Client Utilities $ 26,758.29 $ 35,000.00 $ 40,800.00 General Insurance $ 10'365.57 $ 10'000.00 $ 10\000.00 Repairs& Maintenance $ 14,862.48 $ 11,000'08 $ 1I,000.00 Dumpster Fee $ 2,998.45 $ 3'250.00 $ 3,250.00 Advertising/Public Relations $ 1,453.86 $ 1,500.00 $ 1,500.00 Telephone $ 8,509.08 $ 8,000.00 $ 8,000.00 Office Supplies $ 4'387.50 $ 3'700.00 $ 3,700.00 Bank Charges $ 5,859.94 $ 5,600'00 $ 5,600.00 Postage $ 2,329.70 $ 1,950.00 $ 1,950.00 Publications $ 510.40 $ 1,150.00 $ 1,150.00 DocuSign Envelope ID:71415AD7-D o�4C��9A9-F93F7208DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Dues/Training $ 4,025.55 $ 5,300.00 $ 5,300.00 Travel $ 1,850.49 $ 5,200.00 $ 7,819.00 ~ Printing $ 2,017.86 $ 1,350.00 $ 1'350.00 Computer/Copier $ 5,124.87 $ 8,208.00 $ 8,200.00 Merchandise-Resale $ 408.50 $ 1,000.00, $ 1,000.00 Depreciation Expense $ 22,715.89 $ 1I,420.00 $ 1I,420.00 Miscellaneous Expense $ - $ 100.00 $ 100.00 Volunteer Recognition $ 805.87 $ 1,100.00 $ 1,100.00 Taxes& Licenses $ 408.23 $ 490.00 $ 490.00 Food-Non Cash Donations $348,534.08 $330L000.00 $ 330\000.00 Food Purchased MOW&SRM $ 55,38I.48 $ 60\270.00 $ 75,045.00 Fundraising Expense $ 2,958.21 $ I,800.00 $ 1,800.00 Client Healthcare $ 789.33 $ 1,000.00 $ 1,000.00 Client Water Assistance $ 9,059.59 $ 14,000.00 $ 14,000.00 Emergency Lodging $ 311.47 $ 500.00 $ 500.00 Client Rent $ 5,021.50 $ 7,000.00 $ 7,000.00 Board Expense $ 1,590.82 $ 2,000.00 $ 3,000.00 Contingency $ 5,175.42 $ 4,000.00 $ 4,000.00 $OAU,337.7O $926,400.80 $ 963,194.00 . DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROG A M INFORMATION (Submit a separate Section 3 for each program) Program Name: Samaritan Relief Ministry Program Primary Contact and Title: Kay Stagner, Manager of Client Services Telephone Number: 919-732-6194 ex.12 E-Mail: ocimsrmembargmail_com a) Indicate the type of Human Service Needs Priority, if program applicable: X Priority Area #1: safety-net services for disadvantaged residents Lii Priority Area#2: education, mentorship, and afterschool programming for youth facing a variety of challenges X Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Public Housing Program Category Youth Adult Elderly Disabled Neighborhoods/Residents Affordable Housin. Affordable Healthcare Education Famil Resources Jobs/Jobs Training Food X X X X Transportation Other: Financial assistance for rent, utility, prescription medication X X X X c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. • Orange County Department of Social Services: The Samaritan Relief Ministry receives referrals for individuals and families needing food and emergency financial assistance. • Orange County Health Department: 'WIC" and other maternity/young children related programs make referrals for food, baby formula, and diapers. • Lutheran Family Services and other ental health case management programs: social workers and case managers refer clients to the Samaritan Relief Ministry for food. PRnrs.RAM 11\1Mr)MATICW 1/.q1/9n17 R.411-7,4 AM Pr 1 r ff,31 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Ora ge County Schools: Social workers refer students and their families for food. During the holidays some schools hold food drives that are vital to restocking the Samaritan Relief Ministry food pantry. For the past three years, Cedar Ridge High School has held a coat drive. The coats were brought to the Samaritan Relief Ministry for distribution to people needing warm coats. • Private and Charter Schools: These schools are becoming more active in collecting food for the pantry. • Area Congregations: Pastors of OCIM member congregations make referrals for food and financial support for people within these congregations. Food referrals are available to people who are initially unaware of Orange County Department of Social Services and choose to go to churches for help. Many donations to the Samaritan Relief Ministry food pantry come through monthly food collections as well as general donations to the Samaritan Relief Ministry. Many of the Samaritan Relief Ministry volunteers come from member congregations. • Orange County Sheriff's Office: The Sheriffs Office held a fan drive this summer and OCIM received many fans to distribute to people in need. • Food Bank of Central and Eastern NC: The Samaritan Relief Ministry receives food at low or no cost. • Inter-Faith Food Shuttle: The Samaritan Relief Ministry receives produce and other food for a very low fee. The food has previously been delivered at no cost to our agency. Because of their own budget challenges, a small fee was initiated in 2016. • PORCH Chapel Hill & Hillsborough: The Samaritan Relief Ministry pantry receives monthly donations of non-perishable food items from local neighborhoods. • Food Lion Stores: A local Food Lion store donates "pulled" or "near date" produce, meat and bakery goods. They also provide food through the sale of their "Holiday's without Hunger"boxes. • Weaver Street Market: Through special fundraising campaigns, the pantry receives weekly deliveries of fresh eggs and apples. Beginning winter 2017, seasonal vegetables with accompanying soup recipes will be delivered to the pantry. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: PPnr-ZRAA/1 1111FnRAA47-1()A1 1n1/7(117 R41-2,4 AAA P r. 9 ni DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) Summarize the program services proposed and how the program will address a Town/County priority/goal? The Samaritan Relief Ministry provides groceries and financial assistance for rent, utilities, and prescription medication for families and individuals living in northern Orange County. This program aligns with Orange County's Goal 1: Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Oran.e Count 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. The Samaritan Relief Ministry provides food and emergency financial assistance (rent, utilities, pharmacy) for people living in northern Orange County. Over the years, as the community has grown, the need for emergency assistance has grown. For historical perspective, in 1990, there were 94,232 people living in Orange County. That year the Samaritan Relief Ministry assisted 4,327 individuals, 3009 of those were assisted with food; In 2015, there were an estimated 140,144 people living in Orange County. The Samaritan Relief Ministry assisted 10,775 individuals, 9,497 of those were assisted with food. For families and individuals living in northern Orange County, the OCIM food pantry is the primary place to receive emergency food. The financial assistance that is available to help with rent, utilities, and prescription medication is often one part of the "package" to help people stay in their homes and keep basic utilities available. Because the Samaritan Relief Ministry requires referrals from the Orange County Department of Social Services for financial assistance, the social workers can count on OCIM to be one piece in helping clients get large bills paid or to be available when all public funds have been exhausted. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The Samaritan Relief Ministry provides services to people living within the geographical boundaries of the Orange County School District. This area is primarily rural, with Hillsborough being the largest municipality. The Chapel Hill/Carrboro area is served by the Inter-Faith Council for Social Services. The Samaritan Relief Ministry is a referral-based program. Various Orange County departments, school social workers, pastors, mental health programs, and local non-profits make referrals for their clients who are in need of the services this program offers. g) Describe the credentials of the program manager and other key staff (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Kay Stagner is the Client Services Manager; she has managed the Samaritan Relief Ministry for over 19 years. Kay is from the northern Orange County community and is knowledgeable of community and its resources. When the program manager has to be out of the office, the Meals on Wheels Coordinator (who shares office space) and volunteers answer the office phone and receive referrals. They are trained by the program manager over a period of several weeks. There is a reference file they can refer to if there are questions. Food pantry volunteers are given an orientation and shadow an experienced volunteer until they are able to work independently. All volunteers have had references checked and a Confidentiality Statement signed prior to beginning volunteer duties. PR(10.RAA4 INMPAAAT1(1111 1/11/91117 R-41-74 AAA P f Q DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION h) Describe the specific period over which the activities will be carried out and include an implementation timeline. The Samaritan Relief Ministry is open year-round, Monday-Friday, 9:00 a.m.-5:00 p.m.; households are able to receive food from the pantry a total of seven times during a 12- month period. As long as a request is not made twice in one week the time between food referrals does not matter. Financial assistance has a maximum amount (usually $100) available every six months. 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) In a healthy and caring community, people should not be hungry because they are unable to afford food. They should not have to have utilities shut off because they had to pay for car repairs so they could continue to get to work. People should not be evicted from their home because they lost their job and have not been able to find another one soon enough to pay rent.The Samaritan Relief Ministry cannot help all people with all of their financial needs, but we can partner with Orange County in helping the most financially fragile members of our community. Food and financial donations come to the Samaritan Relief Ministry by community members who care deeply about the quality of the community they live in. OCIM is the conduit by which the members of the community with plenty share with those without. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If the Samaritan Relief Ministry did not receive funding from Orange County, fresh milk and meat purchases would be greatly reduced and during the summer and fall when donations are low, additional non-perishable food could not be purchased; 85 households would not receive help with rent and utilities and the program manager would have to either have a cut in pay or funds would have to be diverted from other areas to pick up the balance. k) Include any other pertinent information. The program demographics show duplicated numbers. Each time a household is assisted, it draws from the program resources and each time is considered a separate "crisis"for the household. Some households may only need help once, while others need help the maximum number of times. For the demographic information, gender is only collected for adults. For informational purposes, children are divided 50% male and 50% female. Ethnicity and Geographic Location are collected by household, not individuals; the chart will reflect that difference. Likewise, we collect age group information a little bit differently; the chart will reflect the difference. We are able to track geographic location by street address. *Hillsborough and *Mebane addresses are not separated by `in'or 'out'of the city limits. PRCY;RLIAA INMPAAATInN 1111/9n17 R.41-74 AM P 1 Q DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information I) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability. Program Target Population Demographics Actual Estimated Projected 2016 2017 2018 2015-16 2016-17 2017-18 Gender Male 4879 4879 5025 Female 5833 5833 6008 Total 10,712 10,712 11,034 _ Ethnicity by HOUSEHOLD African-American 1549 1549 1591 American Indian or Alaska Native Asian – Caucasian 1971 1971 2026 Native Hawaiian or other Pacific Islander Other:specify_Latino 217 217 233 Total 3,737 3,737 3850 -- ----— Of the above, how many Hispanic/Latino 217 217 233 Of the above, how many non-Hispanic/Latino 3520 3520 3617 Total 3,737 3,737 3850 Age 0-5 years 1471 1471 1520 -- 6-18 years 2921 2921 3013 19-50 years 6032 6032 6226 65+years 257 257 275 Total 10,712 10,712 , 11,034 Geographic Location by HOUSEHOLD 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 2291 2291 2360 *City of Mebane (Orange County) 524 524 540 Orange County(Outside Municipalities) 922 922 950 Total 3,737 3,737 3850 PPnr4RAlui INFrVailATInAl 1/11/7(117 R41 74 AM P :.4 r: 1_, c f) f Q DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART( pecific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. O Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents) O 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.) O 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.) O Actual Program -esults use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for: Program Samaritan Relief Ministry 1. Program Activity Name Provide emergency groceries to food insecure households Program Goal Provide a week's worth of groceries to referred households a maximum of seven times in 12 months. Performance Measures Track the number of times individual households receive food through Access database. Produce monthly report of total number of individuals receiving assistance. Previous Year Program Results 9,478 individuals(-3,791 households) received food in 2016. Current Year Estimated Results 9,478 individuals(-3,791 households) will receive food in 2017 Next Year Projected Results 9,762 individuals(-3,905 households) will receive food in 2018 2. Program Activity Name Provide emergency financial assistance for rent, utilities, and prescription medication. Program Goal 130 households will receive emergency financial assistance to be able to retain housing, utilities, or necessary medication. Performance Measures Track the amount of financial assistance individual households receive through Access database. Produce monthly report of total amount of financial assistance given. Previous Year Program Results 169 households received emergency financial assistance for rent and utilities in 2016. Current Year Estimated Results 169 households will receive emergency financial assistance for rent and utilities in 2017 Next Year Projected Results 174 households will receive emergency financial assistance for rent and utilities in 2018. 3. Program Activity Name Program Goal Performance easures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PRir)P.PtiAn INMPA/14771-1A1 11'41/91117 R.41.9d AJtA P f Q DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION n) Program Budget 1. Submit your program budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, 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 ext 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? .55% 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 2016 Estimated 2017 Projected 2018 Total Cost of Program 506,871.33 511,499 526,449 Total # of Individuals 10,712 10,712 11,034 Cost Per Individual 47.32 47.75 47.71 PRCY4F?A11/1 1111FIIRMATtnni 1/q1/9(117 R-41.24 11M p n r, f ° DocuSign Envelope ID:71415AD7-D o�4C��9A9-F93F7208DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Orange Congregations In Mission Samaritan Relief Ministry REVENUE Account Title 2016 Actual 2017 Approved Budget 2018 Contributions $ 10,325.63 $ 25,000.00 $ 25,000.00 United Way $ 33,745.50 $ 14,500.00 $ 14,500.00 Fuel-Duke Energy Foundation $ 8,652.27 $ 9,000.00 $ 9'000.00 Water Assist.Grant Hillsborough $ 7,788.95 $ 5,600.00 $ 5,600.00 Food Contribution-Cash $ 21,643.40 $ 19^000.00 $ 19,000.00 Food Contribution-Non Cash $348,534.08 $33[l000.0U $330,000.00 Local Grants (Orange County) $ 33,416.00 $ 33,415.00 $ 58,415.00 Other Grants $ ],800.0] $ 6,500.00 $ 6,500.00 Fundraising $ 9,072.68 $ 3,000.00 $ 3,000.00 Walk for Hunger $ 5,976.50 $ 6'000.00 $ 6,000.00 FEMA $ 13,246.00 $ 15,000.00 $ 15,000.00 $495,201'00 $467,015.00 $492,OlS.00 Orange Congregations In Mission Samaritan Releif Ministry EXPENSES Account Title 2016 Actual 2017 Approved Budget 2018 Salaries $ 55,131.69 $ 52,300'00 $ 52,300.00 Retirement Plan Contribution $ 1,373.67 $ 875.00 $ 875.00 Payroll Taxes $ 4,371.92 $ 4,254.88 $ 4,254.00 Group Insurance $ 7,897.66 $ 8,000.00 $ 8,000.00 Accounting Fees $ 7,452.25 $ 12,000.00 $ 13,000.00 Utilities $ 2,578.21 $ 3,000.00 $ 3,000.00 Client Utilities $ 26,758.I9 $ 35,000.00 $ 40,000.00 General Insurance $ 2,295.90 $ I,400.00 $ 2,400.00 . Repairs& Maintenance $ 4,794.57 $ 3,000.00 $ 3'000.00 Dumpster Fee $ 499.77 $ 550.00 $ 550'00 Advertising/Public Relations $ 363.47 $ 300.00 $ 300.00 Telephone $ 1,827.69 $ 1,500.00 $ 1'500.00 Office Supplies $ 791.29 $ 1,000.00 $ 1,000.08 Bank Charges $ 136.73 $ 200.00 $ 200.00 Postage $ 578.16 $ 500.00 $ 500.00 Publications $ 127.6I $ 300.00 $ 300.00 Dues&Training $ 197.50 $ 400.00 $ 400.00 Travel $ 49.32 $ 50.00 $ 50.00 Printing $ 409.47 $ 250.00 $ 250.00 Computer/Copier $ 1'288.56 $ 2'300.00 $ 2,200.00 Depreciation $ 474.37 $ 300.00 $ 300.00 Awards& Regognition $ 137.87 $ 200.00 $ 200.00 Taxes& Licenses $ 103-06 $ 70.00 $ 70.00 Non-Cash Food Donations $348'534.08 $330,000.00 $33[\00O.OU DocuSign Envelope ID:71415AD7-D o�4C��9A9-F93F7208DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Food Purchased $ 22,393.74 $ 30\000.00 $ 40L000.00 Fundraising Expense $ 1,123.58 $ 300.00 $ 300.00 Client Healthcare $ 789.33 $ 1,000.00 $ 1,000.00 Client Water Assistance $ 9,059.59 $ 14,000.00 $ 14,000.00 Emergency Lodging $ 311.47 $ 500.00 $ 500.00 Client Rent $ 5,021.50 $ 7,000.00 $ 7,000.00 $506,871.33 $511'449.00 $526,4-49.00 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Meals on Wheels Program Primary Contact and Title: Kay Stagner, Manager of Client Services Telephone Number: 919-732-6194 ext.12 E-Mail: ocimsrm( embargmail.com a) Indicate the type of Human Service Needs Priority, if program applicable: Priority Area #1: safety-net services for disadvantaged residents El Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges X3Priority Area#3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Public Housing Program Category Youth Adult Elderly Disabled Neighborhoods/Residents Affordable Housing Affordable Healthcare Education Family Resources Jobs/Jobs Training Food X X X Transportation Other: Please specify c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. • Orange County Department of Social Services: Meals on Wheels receives referrals about possible recipients from Adult Services social workers. • Orange County Department on Aging: Meals on Wheels receives referrals about possible recipients. Likewise, the Meals on Wheels Coordinator makes referrals to the Department on Aging when recipients seem to be in need of other services or there are health or safety concerns. • Various home health agencies: social workers, nurses and aides make referrals for their clients. • Are. congregations: Members of area congregations volunteer for Meals on Wheels as well as refer people who may need home-delivered meals. • Orange County IE ployees, PHE, Sports Endeavors, Bourough usiness Builders: Employees give up a lunch hour to deliver Meals on Wheels. PRrY4R11A/1 INFrWMATIMI 1/-41/7(117 1:?-16.0=4 IAñ P n a f 9 ")% DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Meals on Wheels Association of A erica: OCIM's Meals on Wheels program is a member of the national organization which provides information, training, and networking opportunities. 'Mayors for Meals" is an event sponsored through MOWAA. This annual event involves mayors from local communities in the delivery of meals on the third Wednesday of March. Through this event, local governments become more aware of Meals on Wheels and the needs of the elderly in our community. Hillsborough's mayor, Tom Stevens, has participated in this event for many years. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? The Meals on Wheels program provides a nourishing, home delivered lunch, five days a week to homebound residents of northern Orange County. This program addresses Orange County's Goal 1: Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents. The Meals on Wheels program ensures the people it serves are receiving a nutritious meal, five days a week. The volunteers are able to make a quick assessment of each recipient's physical and cognitive condition; if there appears to be a change in condition, it is reported to the program coordinator who follows through with the recipient's emergency contact or Orange County agencies as appropriate. This network maintains consistent contact with the most fragile members of this community, as well as promoting well-being, by providing at least one nutritious meal a day, five days a week. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange Count 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. According to Orange County's Master Aging Plan, the number of adults age 65+ is estimated to increase by 31% between 2012-2017. By 2030, this population will more than double from its size in 2012, reaching an estimated 31,063 people and making up 17.6% of all Orange County individuals. Orange Congregations In Mission's Meals on Wheels program desires to make sure the most fragile members of the northern Orange County communities receive a home-delivered lunch and accompanying visit by the delivery volunteer. Extra effort is being made to serve people in the very northern part of Orange County, which is currently out of reasonable driving range for volunteers. By partnering with Orange County and utilizing the Cedar Grove Community Center as a drop-off location for meals, the driving distance and time will be greatly reduced for volunteers. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The people who qualify for OCIM's Meals on Wheels program are home alone during the day, unable to prepare a nutritious meal for themselves due to either physical or cognitive disability, and are no longer driving. The individuals this program serves are normally unable to participate in the programs available at the Central Orange Senior Center. Many of the Meals on Wheels recipients are very low income, though the program is open to any person who meets the qualifications. Ideally, if a person has sufficient financial resources, other options are available. A more vague qualification has been whether the person being referred lives within, or near, an existing Meals on Wheels route. When the Meals on PRCY41=2.4AA 1111MRAA4-rirmi 11q1/2(117 $ 61)Q AM P n r, 1 4. f 9 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Wheels Coordinator receives a referral, she calls either the person needing the service or an identified family member. Basic questions are asked, including where in Orange County they live. If it appears the person meets the qualifications, the coordinator goes to the home to get clear directions and to discuss the financial sliding scale. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) The Meals on Wheels Program Coordinator has been running OCJM's Meals on Wheels program for 11 years. As a former secretary and office manager to a prosecuting attorney, she is able to manage a very detailed and very confidential program. When the Meals on Wheels Coordinator is unavailable, the Manager of Client Services- program supervisor fills in. Volunteer drivers have had references checked and Confidentiality Statement signed prior to volunteering. They are given an orientation and then assigned to a route. Route books are very self-explanatory; if the volunteer is uncomfortable, they are encouraged to ride along with an experienced driver the first time. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Meals are delivered Monday through Friday, between 10:30 and 12:00. During winter storms, when the Orange County Schools are closed due to road conditions, the Meals on Wheels program does not deliver. Prior to anticipated storms, an additional meal of non- perishable items is sent with the understanding that no meal will be delivered if roads are dangerous. 0 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) The Meals on Wheels program serves the most fragile of northern Orange County's residents. Receiving a nutritious lunch is one part of allowing seniors to "age in place."By providing a daily "well-being"check, significant changes in physical condition and cognitive behaviors can be recognized and the Coordinator is able to alert absent family members to potential problems. There have been several occasions when a recipient has fallen. Without someone checking on them, a minor situation can easily escalate to an emergency. In the case of an emergency, Emergency Services is called. The need for expansion to the more northern parts of the county is an issue this Meals on Wheels program has been wrestling with for several years. All routes are driven by volunteers, many of whom drive during their lunch break from work. The time it would take and the price of gasoline have been prohibitive in reaching people in the Cedar Grove and Little River townships. By using the Cedar Grove Community Center as a secondary food distribution site, residents from those communities would be more likely to volunteer to drive. Having enough volunteers would make it viable to add recipients who may have previously lived too far away to serve. Caring for the elderly and in firmed is a very important component of a healthy community. PRnr:RAAil INM1:211/111TInAl 1/q1/7n17 R..'1R-11Q AAA P nr DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If the current Meals on Wheels program did not receive funding from Orange County, the program would be unable to continue as it currently exists. Without the Orange County funds, so few meals could be purchased that the program would have to either offer no sliding payment scale and only be available to people who could afford the full cost or only be available to a very few people. If there is no funding for personnel support, there would be no expansion of routes to the Cedar Grove and Little River areas. A new position for a Meals on Wheels Assistant would be imperative; the part-time Meals on Wheels Coordinator would not be able to transport, supervise, and be available to drive a route if a volunteer does not show up, while also being available to do the same thing for the existing six routes. k) Include any other pertinent information. Because the actual people going on and off Meals on Wheels can vary daily, the actual number of meals delivered is used for quarterly reporting. The Cedar Grove Community Center is 9.7 miles from Orange Congregations In Mission, a round trip is 19.4 miles. At .54 cents per mile, the annual cost for meals to be delivered to Cedar Grove would be $2,619.00. ppnr,PAAA INMRMATICMI lflhf2fll7 R-qR.nc) P I i nf2 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program information I) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2016 2017 2018 2015-16 2016-17 2017-18 Gender Male 25 27 32 Female 56 59 65 Total 81 86 97 Ethnicity African-American 38 40 43 American Indian or Alaska Native Asian _ Caucasian 43 46 43 Native Hawaiian or other Pacific Islander Other:specify Total 81 86 97 Of the above, how many Hispanic/Latino Of the above, how many non-Hispanic/Latino 81 86 97 Total 81 86 97 Age 0-5 years • 6-18 years 19-50 years 2 2 2 51+years 79 84 95 Total 81 86 97 Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing =MI Town of Chapel Hill(Non-Public Housing) Town of Carrboro Town of Hillsborough 50 52 City of Mebane (Orange County) IFMMMII 2 2 Orange County(Outside Municipalities) 29 33 43 PRCV-V2A AA IA/FnRAA4 TlnAl 1/11/2fl17 R-QF.nc4 AAA P r; r) 1 7 n 9 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Total 81 86 97 1 Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART( pecific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. O 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. (Le. Delivered an average of 105 meals per day.) Work Statement Chart for Program: Meals on Wheels 1. Program Activity Name Deliver meals to elderly/disabled residents. Program Goal Deliver 45 meals per day(70 people for the year), Monday-Friday. Performance Measures Will track the number of meals delivered each day. Previous Year Program Results 81 people received meals in 2016, daily average of 42. Current Year Estimated Results 86 people will receive meals in 2017, daily average of 43. Next Year Projected Results 91 people will receive meals in 2018, daily average of 45. 2. Program Activity Name Increase meal delivery to the Cedar Grove and Little River township& Program Goal Deliver meals to an additional six people, distributed from the Cedar Grove Community Center. Performance Measures Will track the number of meals delivered each day. Previous Year Program Results This is a new initiative. Current Year Estimated Results This is a new initiative. Next Year Projected Results Six people in the Cedar Grove and Little River townships will receive Meals on Wheels delivery. 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 lA1PriF?AllATInAl 1/q1/21)17 R-1A-t7Q AAA P R n DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION n) Program Budget 1. Submit your program budget. You may complete the provided template (separate xis file) or you may submit your own budget file (as long as it contains the same information, 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? .07% 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 2016 Estimated 2017 Projected 2018 Total Cost of Program 65,745.47 62,400 79,400 Total # of Individuals 81 86 97 Cost Per Individual 811.61 725.58 818.55 PROG:RIIAA !NMI:a/1 -17()N 1 tR1/7n17 R•qR.I1Q 4AA P 2 n n f 7 DocuSign Envelope ID:71415AD7-D o�4C��9A9-F93F7208DC62 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Orange Congregations In Mission Meals on Wheels ^ REVENUE Account Title 2016 Actual 2017 Approved Budget 2018 Contributions $ 4`893.43 $ 5,000.00 $ 5,000.00 United Way $26,650.40 $18,661.00 $18,661.00 Local Grants $17,000.00 $17,O0].UU $34,000.00 Other Grants $ 3,150.00 $ 5,000.00 $ 5,000.00 Fundraising $ 966.49 $ 1,000.00 $ I,000.00 Walk for Hunger $ 3,635.08 $ 8,000.00 $ 8,000.00 Client Fees $ 5^788.80 $ 6,000.00 $ 6,000.00 $62,085.19 $80,661.00 $77,661.00 Orange Congregations In Mission Meals on Wheels EXPENSES Account Title 2016 Actual 2017 Approved Budget 2018 Salaries $12,Ql8.S6 $I1,500.00 $25,900.00 Payroll Taxes $ 988.27 $ 950.00 $ 950.00 Group Insurance $ 196.89 $ 350.00 $ 358.00 Accounting Fees $ 9,656.I5 $ 7,000.00 $ 7,000.00 Utilities $ 1,385.31 $ 1,200.88 $ 1,200.00 General Insurance $ 797'30 $ 500.00 $ 500.00 Repairs& Maintenance $ 3,443.28 $ 2,008.00 $ 2,000.00 Dumpster Fee $ 499.77 $ 500.00 $ 500.00 Advertising/Public Relations $ 363.46 $ 200.00 $ 200.00 Telephone $ 1,827.70 $ 1,500.08 $ 1,500.00 Office/Shop Supplies $ 791.29 $ 500.00 $ 500'00 . Bank Charges $ 36.59 $ 10.00 $ 10'00 Postage $ 578.20 $ 450.00 $ 450.00 Publications $ 127.59 $ 200.00 $ 200.00 Dues&Training $ 410'00 $ 580.00 $ 500.00 Travel $ 235.65 $ 1,950.00 $ 4,569.80 Printing $ 409.46 $ 100.00 $ 100.00 Computer/Copier $ 1,385'21 $ 2,000.00 $ 2,000.00 Depreciation Expense $ 2.53 $ 100.00 $ 100.00 Awards & Regognitions $ 137.88 $ 400.00 $ 400.00 Taxes& Licenses $ 102.05 $ 70.00 $ 70.00 Food $Z9,428.75 $30L170.00 $3S'O45.UU Fundraising Expense $ 23.58 $ I50'00 $ 250.00 $65^745'47 $62,400.00 $84,294.00 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 EXHIBIT `B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Orange Congregations in Mission Program Name: Samaritan Relief Ministry Funding Award: $37,415 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel-Program Manager Salary 7,915 Rent and Utility assistance 10,000 Food 19,500 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Emergency financial assistance for families facing eviction or utility shut-off. • A week of groceries, seven times a year for households facing hunger. • 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 Qualified households receiving financial assistance for rent and utilities. 165 Number of individuals receiving groceries. 9,350 DocuSigned by: tAit. S(u r&lit, S. FIttaalaExecutive Di rector 10/11/2017 Certified by: gP62F�nF,coa$3 Title: Date: (Provider's Signature) DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 EXHIBIT `B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Orange Congregations in Mission Program Name: Meals on Wheels Funding Award: $34,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Meals on Wheels meal purchases $17,000 Personnel-Client Services assistant salary and mileage to Orange County Cedar Grove Center $17,000 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Home delivered meals, five days a week to frail,home-bound recipients • Home delivered meals, five days a week to frail, home-bound recipients in the rural, northern parts of Orange County. • 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 Number of meals delivered to Meals on Wheels recipients 5,230 Meals disbursed from Orange County's Cedar Grove Community Center 2,000 DocuSigned by: J c' ' S�talvol� ' F i, Executive Director 10/11/2017 Certified by: RF67EC6D675A483 Title: Date: — Late. (Provider's Signature) DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 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: St ant& S. Fruioul, Executive Director 10/11/2017 Certified by: BE62EC6D675A483... Title: Date: (Provider's Signature) (Orange Congregations in Mission) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:71415AD7-DCDD-4CF6-89A9-F93F72D8DC62 OP ID: LP A °R°w CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 07/14/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Jeff Rubish High&Rubish Insurance Agency PHONE FAX P.O. Box 3040 (NC,No,Ezt>:919-913-1144 (A/C,No); 919-913-1155 6015 Farrington Rd.Ste 101 E-MAIL natalie hi handrubish.com Chapel Hill,NC 27517 ADDRESS: 9 Jeffrey A. Rubish PRODUCER OCIM--1 Y CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED Orange Congregations In INSURER A:Cincinnati Insurance Company 10677 Missions,Inc. INSURER B:Hartford Underwriters Ins. 30104 300 Millstone Drive Hillsborough, NC 27278 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE I POLICY EFF POLICY EXP NSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 A X COMMERCIAL GENERAL LIABILITY X ECP0349072 10/15/2015 10/15/2018 DAMAGE TO RENTED PREMISES(Ea occurrence) $ 2,000,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 4,000,000 X POLICY PRO- JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) 2,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE A X HIRED AUTOS EBA0349072 10/15/2015 10/15/2018 (PER ACCIDENT) X NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y N B ANY PROPRIETOR/PARTNER/EXECUTIVE / 22WECBV6360 08/18/2017 08/18/2018 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER in NH)EXCLUDED? N/A 22WECBV6360 08/18/2016 08/18/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES Attach ACORD 101,Additional Remarks Schedule,if more space is required) Additional Insured Status Applies to Holder CERTIFICATE HOLDER CANCELLATION ORANG-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ORANGE COUNTY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN O O O Box 81O ACCORDANCE WITH THE POLICY PROVISIONS. P 302 W.Tryon St. AUTHORIZED REPRESENTATIVE Hillsborough, NC 27278 Jeffrey A. Rubish ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD