Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
2017-585-E Finance - Inter-Faith Council for Social Service - Outside Agency Performance Agreement
DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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 Inter-Faith Council for Social Service, a not-for-profit corporation, located at 110 West Main Street, Carrboro,NC 27510 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Inter-Faith Council for Social Service 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 50000 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 12500. 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. (Inter-Faith Council for Social Service) Orange County Outside Agency Performance Agreement Revised 7/2017 Page 1 of 7 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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. (Inter-Faith Council for Social Service) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7/17 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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. (Inter-Faith Council for Social Service) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7/17 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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 Inter-Faith Council for Social Service 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: (Inter-Faith Council for Social Service) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7/17 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C County: Finance &Administrative Services Provider: Inter-Faith Council for Social Orange County Service Post Office Box 8181 110 West Main Street Hillsborough,NC 27278 Carrboro,NC 27510 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 c�ohdfdof the Provider UL JuAlS 10/16/2017 a 617znsaEFFo4A9... Date (Inter-Faith Council for Social Service) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7/17 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C E a r a?alibi ebtiialf of Orange County Government ot&uut, komoku(sLu? 10/23/2017 06379949755E477... Bonnie Hammersley, County Manager Date (Inter-Faith Council for Social Service) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7/17 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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 w w Qs 40111111111W l'',e. .. % 'Iv' ol,,l1111111111 II 111111111111 aV S y �� 01110 0000 logo, 1111 Ff �s � � ° o1 fit DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XH I 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 easures 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 J nu ry 31 A III III III urc ul uir m.m I urr o s s urn uris re 00 hie March - May Application Review & Agency Presentations June Agency Funding Approval by Board/Council July Contracts Executed & Programs Begin DO NOT SUBMIT THIS PAGE 1/31/2017 11:43:55 AM Page 2 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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 ervice Town arr oro Applications are accepted once a year and reviewed by the Town's Human Services Advisory Commission, which makes a recommendation for funding to the Board of Aldermen for final approval. For more information about the Town of Carrboro Human Services program, see here. Questions and submittals should be directed to: Annette Stone, 301 W. Main Street Carrboro, NC 27510 919-918-7319 astone(ctownofcarrboro.or Submission: ➢ We strongly encourage applications to be single-spaced, with 12-point anal 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 1/31/2017 11:43:55 AM II II' ago 3 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Human ervice Town a el Hill In 1982, the Town established local funding to support local nonprofit organizations that carry out human service work throughout the community. Applications are accepted once a year and reviewed by the Town's Human Services Advisory Board, which makes a recommendation for funding to the Town Council for final approval. For more information about the Town of Chapel Hill Human Services program, see here. Questions and submittals should be directed to: Jackie Thompson 405 Martin Luther King Jr. Blvd. Chapel Hill, NC 27514 919-969-5081 jhompsontownofchapelhill.or Submission: ➢ We strongly encourage applications to be single-spaced, with 12-point anal font and normal margins. ➢ Application: Two (2) paper copies of the application with ORIGINAL signatures must be hand delivered or mailed to Jackie Thompson, 405 Martin Luther King, Jr. Blvd., Chapel Hill, NC 27514; AND ➢ Attachments: The application submittal must be accompanied by a flash drive with the application and all attachment files in electronic format. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. Human ervice Orange County For more information about the Orange County Human Services program, see here. Questions and submittals should be directed to: Allen Coleman PO Box 8181 Hillsborough, NC 27278 (919) 245-2151 acoleman@oran ecountync. ov 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 1/31/2017 11:43:55 AM Page o .t 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency Received By Program(s) Date/Time / Section Subsection 1. Cover Page a. ❑ Applicant Contact Information b. ❑ Funding Requests c. ❑ Signed Application Cover Page d. ❑Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. ❑ Agency's Years in operation b. ❑ Agency's Purpose/Mission c. ❑ Agency's Types of Services Provided d. ❑ Agency's Experience with Programs e. ❑ Other Pertinent Agency Information f. ❑ Schedule of Positions g. ❑ Living Wage h. ❑ Agency Budget 3. Program Information a. 111 Human Services Needs Priority b. ❑ Type of Program A separate Section 3 is c. ❑ Agency Collaboration required for each program. d. ❑ Summary of Program e. ❑ Description of Identified Need f. ❑ Description of Population to be Served g. ❑ Program Staffing, Capacity, & Expertise h. ❑ Program Implementation Timeline i. ❑ Value of Investment j. ❑ Impact of Reduced/No Allocation k. ❑ Other Pertinent Information I. ❑ Target Population/Beneficiary Chart m. ❑ Work Statement n. ❑ Program Budget, Detail, & Cost per Individual 4. Attachments a. ❑ Audit: Organizations receiving $300,000 or more in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ❑ NC Solicitation License d. ❑ IRS Federal Tax-Exemption Letter e. ❑ Certificate of Insurance f. ❑ List of Board of Directors g. ❑ Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 1/31/2017 11.43.55 AM Pago 5f 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Inter-Faith Council for Social Service Applicant Organization's Physical Address: 110 W. Main Street Carrboro, NC 27510 Applicant Organization's Mailing Address: 110 W. Main Street Carrboro, NC 27510 Applicant Organization's Web Address: www.ifcweb.org Executive Director: John Dorward and Kristin Lavergne Telephone Number: 919-929-6380 E-Mail: info©ifcmailbox.org Tax ID Number: b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested — For All Procirams) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total - HS Hill - HS County-HS Residential Services: Community House and HomeStart offer housing, meals, showers and 6,000 13,500 26000 45,500 laundry, health, mental health and dental care, social work and referrals. Food Programs: The Community Kitchen offers free hot meals every day to anyone who is hungry, and the 4,950 10,000 22,500 37,450 Food Pantry offers free groceries as often as once a month to our neighbors in need. Support Circles use a relationship-based model to provide support for families and individuals 1,000 1500 1500 4,000 transitioning out of homelessness. Totals 11,950 25,000 50,000 86,950 c) To the best of my knowledge and belief all information and data in this application is true and current. The docum t has been duly authorized by the governing board of the applicant. 7 r January 31, 2017 Signature: . ecutive Director Date -; / January 31, 2017 Signature: Board Chairperson Date AGENCY INFORMATION 1/31/2017 11:43:55 AM Pago 3 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® c) Current beneficiaries of the program for which funds are being requested? ❑ ® d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in t termination of any grant awarded. January 31, 2017 Signature: Ex utive Director Date ,,- January 31, 2017 Signature: B. d i rtp4serrt Date AGENCY INFORMATION 1/31/2017 11:43:55 AM P g / of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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): Since 1963 (53 years) b) Agency's Purpose/Mission (no more than a few sentences): The Inter-Faith Council for Social Service meets basic needs and helps individuals and families achieve their goals. We provide shelter, food, direct services, advocacy and information to people in need. We accomplish this through strong partnerships with volunteers, staff and those we serve. We rely on the active involvement of caring individuals, congregations and other community organizations. c) Types of Services the Agency Provides (bullet format): • Homeless shelters • Community Kitchen • Food Pantry • Crisis Intervention • Support Circles • Robert Nixon Clinic d) Agency's History with Providing These Services: IFC was founded in 1963 to address the significant gaps that existed in the social safety net of our community. Seven local church women created the IFC "to discover unmet needs and to respond through the coordinated efforts of volunteers." With no paid staff or office space, IFC began providing crisis intervention assistance to people in dire need. Today it is a not-for-profit non-denominational social service organization with a small staff providing basic services to combat poverty, hunger and homelessness in Chapel Hill and Carrboro. IFC is the principal agency in Orange County for mobilizing our community to address homelessness, hunger, and economic disparity. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director?Are there new initiatives?) We have hired moss+ross to conduct the search for our next executive director. We have now narrowed it down to two finalists and expect to have the new director on board by April. IFC plans to consolidate the Community Kitchen and Food Pantry into a food operations center called FoodFirst. Having a combined program in one location will maximize food, space, staff and volunteer resources and offer a more efficient and effective way to feed the hungry in our community. Agency Information 1/31/2017 11:43:55 AM Pago of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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: 22 # of FTE - Paid Part-Time Positions: 4 # of Volunteers: 750 # of FTE -Volunteers: 14 g) Living Wage Does this agency pay permanent employees a minimum living wam e? (Yes/No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? Yes If no, please explain. Agency Information 1/31/2017 11:43:55 AM Pago 9 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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 *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) Agency Information 1/31/2017 11:43:55 AM ll ' ago 10 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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? $400 surplus Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. iv. What is your agency's fiscal year? July 1, 2016 through June 30, 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/31/2017 11.43.55 AM P g '1 1 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Residential Services Programs: Community House, HomeStart Program Primary Contact and Title: Stephani Kilpatrick, Residential Services Director Telephone Number: Stephani Kilpatrick 919.967.1086 ext. 12 E-Mail: Stephani Kilpatrick: skilpatrick ifcmailbox.orq a) Indicate the type of Human Service Needs Priority, if program applicable: X Priority Area #1: safety-net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing X X X X Affordable Healthcare X X X X Education Family Resources X X X X Jobs/Jobs Training Food X 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. • Participation on the Orange County Partnership to End Homelessness Leadership Team • Participation on the Orange County Partnership to End Homelessness 100,000 Homes Taskforce, which includes participation in and planning for Orange County Project Connect and the annual Point-In-Time Counts. • The IFC recruits and maintains cooking groups from congregations, neighborhoods, the university and businesses to prepare and serve meals at HomeStart and Community House; • Partnership with Orange County that provides a no-cost 25-year lease of three acres of land where the IFC's HomeStart facility sits. We also collaborate with the County on the Emergency Solutions Grant and Rapid Rehousing; PROGRAM INFORMATION 1/31/2017 11:43:55 AM Pago 12 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • 50-year lease arrangement with the University of North Carolina at Chapel Hill for the IFC @ SECU Community House transitional housing facility for homeless men in partnership with the Town of Chapel Hill and numerous social service agencies; • Partnership with UNC Hospitals and SHAC Clinic for medical care for residents; Partnership with Piedmont Health Services to provide medical, mental health and dental clinics in an onsite satellite clinic of PHS at IFC @ SECU Community House, providing an opportunity for long-term sustainability of health care for all of our residents; • Orange County Literacy Council provides cultural, educational, writing and literacy programs to both male and female shelter residents; • IFC works closely with the Community Empowerment Fund who offer financial education, matching funds savings accounts and job search help to many of our residents; • IFC makes referrals to the Veterans Administration to assist our homeless vets with services; • Longstanding collaborative relationships between Freedom House, The Horizons Program at UNC-CH and AA/NA groups to respond to addiction and substance abuse issues experienced by clients; • Partnership with the Compass Center that provides domestic violence workshops geared toward both women and children at HomeStart. We also work closely with the Center to provide a safe space for survivors to be housed, when appropriate; • Partnership with The Furniture Project, organized by St. Thomas More volunteers and supported by the IFC since its inception, which helps furnish homes for graduates of IFC residential services and others throughout the community who might not otherwise have furniture; • Partnership with the PTA Thrift Shop, which provides clothing vouchers for IFC clients. This long-standing collaboration is a huge help to our many clients who find themselves in need of clothing. 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? Community House offers safe living accommodations, meals, showers and laundry facilities to men in our area experiencing homelessness. Community House guests receive an array of other services including referrals to substance abuse education and counseling; medical, mental health and dental treatment; social worker support;job coaching; and referrals to community agencies. Residents are encouraged to identify and address personal challenges, seek employment opportunities, and establish a plan with short and long-term goals. IFC partners with Piedmont Health Services (PHS) to provide a PHS Satellite Clinic inside Community House to provide health care services to respond to the various needs of homeless men and women. Staff and volunteers strive to empower, educate and support homeless men to take important steps towards a successful transition out of homelessness. There are a variety of volunteer opportunities for individuals and groups available at Community House, which include: evening volunteers, receptionists, building monitors and clinic staff. Community House serves as Orange County's only shelter for homeless men. It also provides 17 emergency shelter cots during inclement weather. HomeStart provides 24-hour emergency and longer-term housing and services to homeless women and children. HomeStart's mission is to provide "a safe, structured home for homeless women and children, helping them to access community resources and offering everyone on- going support to break the cycle of poverty and homelessness." Domestic violence, eviction, PROGRAM INFORMATION 1/31/2017 11:43:55 AM Pago 13 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION unemployment, low-paying jobs, mental illness, lack of support services, family break up and substance abuse are just some of the reasons HomeStart residents find themselves homeless. A range of services including meals, social work, job coaching, health and mental health care are provided. Intensive case management serves as the key tool for helping families to achieve their goals of earning their own income and finding affordable childcare and housing. With the current year's additional funding from CDBG we have doubled the amount of Case Management we provide. HomeStart, located on land provided by Orange County, began as a transitional housing program for homeless families that was a direct outcome of a 1994 Orange County Emergency Family Shelter Task Force. IFC has 2 full-time Social Workers and 7 volunteer case managers who meet with clients to come up with a service plan and then connect them to resources in our community. We have found that intensive case management is key to individuals and families overcoming homelessness. In the past, HomeStart had 1 full-time Social Worker to provide Case Management Services for 10 families. A dramatic cut in funding from the North Carolina Partnership for Young Children (Smart Start) resulted in a reduction in case management support to 15 hours a week for all of the women and families. Recent CDBG funding from 2016-17 has allowed IFC to double the amount of case management for families and reduce the time families need to live in a shelter. Each resident currently receives case management every week in order to set goals and review his/her progress in working towards his/her goals. This frequency is important, as a great deal can happen in the lives of individuals and families during a two-week period. Sometimes not making timely connections to resources such as mental health services or school resources can derail a client's entire plan for becoming self- sufficient. During a case management meeting the case manager and resident look at many different areas such as identifying/contacting local services,job search, job training or schooling, mental health, and housing, etc. They prioritize together how to navigate the confusing/frustrating situation of being homeless. Each resident identifies the next steps that would help them become more stable and end their homelessness. Case notes are written after each session. Once goals have been set, the case manager supports the client's work towards those goals by identifying and making contact with outside service providers such as Orange County Department of Social Services (Work First, Rapid Rehousing, etc.), Vocational Rehabilitation, Freedom House, UNC Horizons program , Durham Tech, and Community Empowerment Fund to name a few. The case manager facilitates the connection and advocates for the client if needed, to ensure timely and effective access. IFC's Residential Programs work towards the Town and County goals of affordable housing, including emergency & transitional housing, as well as the goal to create a place for everyone. Through our partnership with Piedmont Health Systems (PHS), we work toward the goal of affordable healthcare, including additional healthcare options and additional mental health service options. PHS has a satellite clinic in our facility for our residents to access medical, mental health, and dental care. We are also working toward the goal of additional substance abuse services through our participation in the Access to Recovery program; Our Case Managers work toward the goal of increasing access to services through coordination and communication, increasing communication of services and how to access them, and improving coordination of services. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro 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 accordance with the Towns' and County's goal of affordable housing and creating a space for everyone, Community House and HomeStart provide emergency shelter and PROGRAM INFORMATION 1/31/2017 11.43.55 AM P g o of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION transitional housing for homeless individuals and families. The Point-in-Time Count in January 2016 found 80 homeless individuals in Orange County. Over the course of the year, IFC provided shelter to 205 men, 115 women, and 52 children (unduplicated individuals). Our shelters sleep some 50 people per night at each facility and we routinely have more requests than we can meet. Through our partnership with Piedmont Health Systems (PHS), we work toward the goal of affordable healthcare, including additional healthcare options and additional mental health service options. PHS has a satellite clinic located in our building at Community House and this means that residents of both Community House and HomeStart have an easily-accessible clinic with consistent treatment providers. Because we recently began participating in the Access to Recovery program, we are working toward the goal of additional substance abuse services. We have 2 part-time staff persons dedicated to coordinating substance abuse recovery services for our community members. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? IFC's Residential Services Programs serve the area's homeless population. Some of the challenges they face include loss of jobs, significant health-related expenses, loss of housing, disrupted family units and lack of social support. We allow individuals to self-refer, and we also accept referrals from community agencies, including the Orange County Department of Social Services and Compass Center. We are on the Community Resources list put together by the Orange County Partnership to End Homelessness. We are on the Community Resources list put together by the Orange County Partnership to End Homelessness. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Our Residential Services Director holds an MSW from UNC-Chapel Hill and has worked for IFC for over 7 years. She is responsible for both 24-hour residential facilities and oversees a staff of 9 full-time employees and 12 part-time employees. The staff consists of Residential Services Managers, as well as 3 Social Workers. The staff Social Workers oversee 7 volunteer Case Managers and multiple other volunteers responsible for the day- to-day operations of the facilities. Volunteers hold a variety of roles and receive overall agency Orientation as well as shadow staff or seasoned volunteers as part of their training. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. The activities will be carried out over the next fiscal year (July 1, 2017-June 30, 2018) Our residential facilities are 24-hour facilities, open 365 days per year. Shelter is provided every night and just under 80 hours per week of case management services will be available to Community House and HomeStart residents. This program operates regardless of weather conditions. 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) IFC is one of only a few organizations providing safety-net services in our community and its residential programs for the homeless are the only ones in the county. IFC's residential programs have increased efforts to collaborate with other homeless service providers in the PROGRAM INFORMATION 1/31/2017 11.43.55 AM Pago 15 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION county to map services and come up with a comprehensive plan to end homelessness in accordance with HUD goals. IFC is an integral part of bringing funding to Orange County through the Continuum of Care grant from the Department of Housing and Urban Development. The population served in these programs is a vulnerable one and IFC fills the gap in providing services that in many places is fulfilled by local governments. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. IFC would need to consider reducing hours of service or number of clients served. The worst case scenario would be that IFC would have to close one program completely. k) Include any other pertinent information. PROGRAM INFORMATION 1/31/2017 11.43.55 AM Pago 1G of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Proclram Information I) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 150 228 230 Female 142 136 145 Total 292 364 375 Ethnicity African-American 156 228 230 American Indian or Alaska Native 5 7 2 Asian 1 2 1 Caucasian 121 116 130 Native Hawaiian or other Pacific Islander 0 0 0 Other: specify Clients identified as Multi-racial 9 11 12 Total 292 364 375 Of the above, how many Hispanic/Latino 1 2 2 Of the above, how many non-Hispanic/Latino 291 362 373 Total 292 364 375 Age 0-5 years 24 40 42 6-18 years 26 32 33 19-50 years 111 174 180 51+years 131 118 120 Total 292 364 375 Geographic Location Alamance County 11 8 10 Chatham County 3 14 15 Durham County 55 70 75 Wake County 10 48 55 Orange County Breakdown Chapel Hill Public Housing 0 Town of Chapel Hill (Non-Public Housing) 118 124 130 Town of Carrboro 10 18 25 Town of Hillsborough 0 2 City of Mebane (Orange County) 0 1 Orange County(Outside Municipalities) 39 24 30 PROGRAM INFORMATION 1/31/2017 11:43:55 AM P g ' "'/ of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 306 *does not 343 *does equal 364 not equal 375 246 *does not because we because we equal 292 estimate we estimate we because we will serve will serve had 46 clients approximately approximately 58 clients from 32 clients from other NC other NC from other counties or out counties or out NC counties Total of state of state or out of state Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART(Specific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program Residential Services 1. Program Activity Name Residential Services Program Goal Community House and HomeStart will provide safe, emergency shelter and transitional housing, as well as Case Management to reduce obstacles to overcoming homelessness Performance Measures Information logged into the HMIS and an in-house data collection system Previous Year Program Results 292 homeless persons received shelter Current Year Estimated 364 homeless persons receive shelter, with access to Full- Results Time Case Managers Next Year Projected Results 375 homeless persons receive shelter, with access to Full- Time Case Managers 2. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PROGRAM INFORMATION 1/31/2017 11.43.55 AM P go 'Inn of 3 5 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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? 54% 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 2415-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program 1,033,515 1,042,591 1,015,463 Total # of Individuals 292 364 375 Cost Per Individual $3539 $2864 $2708 PROGRAM INFORMATION 1/31/2017 11:43:55 AM Pago 19 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Food Programs: Food Pantry, Community Kitchen Program Primary Contact and Title: Kristin Lavergne, Community Services Director Telephone Number: 919-929-6380, x41 E-Mail: klavergne@ifcmailbox.org n) Indicate the type of Human Service Needs Priority, if program applicable: X Priority Area #1: safety-net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents o) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education Family Resources X X X X Jobs/Jobs Training Food X X X X Transportation Other: Please specify p) 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. • Active participation on Orange County's Family Success Alliance leadership council. The Alliance seeks to improve the lives and opportunities for long term success for children and families struggling to make ends meet. This is done through developing a "pipeline" of coordinated community resources that will ensure the successful passage of children from cradle to career or college; • Collaboration with Farmer Foodshare, TABLE, St. Joseph's Food Ministry, Inter-Faith Food Shuttle, Food Bank of Central and Eastern North Carolina, local grocery stores, restaurants, congregations, UNC at CH dining services and other food programs to gather and distribute the needed food resources; • Collaboration with liaisons representing some 35 congregations who meet regularly for IFC updates, trainings, sharing of information, organizing food collections and mobilizing volunteers and financial resources; PROGRAM INFORMATION 1/31/2017 11:43:55 AM Pago 20 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • The IFC recruits and maintains cooking groups from congregations, neighborhoods, the university and businesses to prepare and serve meals at the Community Kitchen; • IFC Community Services in Carrboro often refers member households to Orange County Department of Social Services for Food and Nutrition, Emergency Assistance and other services. • Last year, Weaver Street Market conducted a successful fundraising campaign to be able to supply bags of apples to Food Pantry member households. In addition, over the holidays they just completed a round up campaign that will allow the Pantry to at least double the amount of fresh produce being given to member households. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: q) Summarize the program services proposed and how the program will address a Town/County priority/goal? The Community Kitchen provides around 68,000 meals to hungry persons every year. Meals are free of charge and are provided to anyone who is hungry as well as to the residents of Community House and HomeStart. Community volunteers and volunteer groups representing congregations, businesses, neighborhoods and the University provide nutritious, hot meals 365 days a year. The Kitchen Coordinator schedules and trains volunteers to prepare and serve meals. Nearly all of the food that is served is donated by local restaurants, food services, campus groups, farmers, congregations and businesses. The Community Kitchen relies heavily on volunteers to prepare and serve meals and clean up afterwards. Meal monitors provide support to volunteer groups and address client needs during the meal. Volunteers also help pick up, receive, sort and store food donations. The Food Pantry provides around 1,100 bags of groceries to those in need every month. Households in Chapel Hill or Carrboro, or in which an adult works in those communities, may become members of the Pantry and are welcome to receive groceries once a month. Grocery quantities offered are based on the number of people in the household. Food Pantry members may be eligible for other services. Staff, student interns and community volunteers receive, sort and stock food, interview clients and greet visitors at the reception desk. Evening hours are provided through a special collaboration called Project Rush Hour, which is primarily UNC students that volunteer to keep the Pantry open until 7 two days a week. The IFC relies on donations from individuals, congregations, community food drives, grocery stores, UNC campus, the Inter-Faith Food Shuttle and the Food Bank of Central and Eastern North Carolina. The Pantry also partners with Farmer FoodShare to receive fresh locally-grown produce that is distributed with non-perishables. With community donations and hands-on help, holiday dinners are distributed at the end of November and December to member households that have pre-enrolled. Both these Food Programs are safety-net services for disadvantaged residents. Food is a basic human need and these programs work to meet that need. r) 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. PROGRAM INFORMATION 1/31/2017 11:43:55 AM Pago 21 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION According to the latest data available from Feeding America, Orange County had an overall food insecurity rate of 15.4 percent and 20,900 food insecure people. In the Chapel Hill- Carrboro City Schools, 60% of preschool children, 30% of elementary school children and 24% of middle school students receive free and reduced price meals. The Chapel Hill Human Services Need Assessment states that food is another significant human need identified by community stakeholders. Many nonprofit organizations address the need for food, especially local, healthy food options. However, more needs to be done. IFC's Community Kitchen and Food Pantry are available free of charge to those facing hunger in the Chapel Hill-Carrboro community. Both programs continually make efforts to incorporate as much fresh, healthy food into their offerings as possible. s) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The Food Programs serve households that live in our community that are in need of a hot meal or groceries. We allow individuals to self-refer, and we accept referrals from community agencies, including the Orange County Department of Social Services. We are on the Community Resources list put together by the Orange County Partnership to End Homelessness. t) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) IFC has been providing basic needs programs for the past 52 years and has a demonstrated track record of success. The Community Services Director has a Master in Social Work degree from UNC-Chapel Hill and has worked at IFC for 22 years, more than half of which are in this position. There are 3 Client Services Representatives that work with each other and the volunteers to operate the Food Pantry program on a day to day basis. Our Kitchen Coordinator has years of experience in food service and volunteered in the Kitchen before he came on as staff. He has 3 part-time assistants that provide the coverage to work with the volunteers serving lunch and dinner as well as receive and process food donations between the hours of 9 am and 8 pm. u) Describe the specific period over which the activities will be carried out and include an implementation timeline. The activities will be carried out over the next fiscal year. The Food Pantry is open from 9am to 5pm on weekdays. On most Tuesdays and Wednesday the pantry stays open until 7pm. The Community Kitchen serves lunch Monday through Saturday 11:15am-12:30pm, Sunday 12:15pm-1:30pm, and dinner Monday through Friday 6:15pm-7:OOpm. v) 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) IFC is one of only a few organizations providing these type of safety-net services in our community. Food is at the base of Maslow's Hierarchy of Needs. If people are hungry, achieving other goals, including participating fully in their community, will be difficult. PROGRAM INFORMATION 1/31/2017 11:43:55 AM Pago 22 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION w) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. IFC would need to consider reducing hours of service, number of meals provided, or number of clients served. The worst case scenario would be that IFC would have to close one program completely. x) Include any other pertinent information. PROGRAM INFORMATION 1/31/2017 11.43.55 AM Pago 23 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Proclram Information y) Target Population (this table is for FoodFirst and Support Circles) 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 2000 1868 1840 Female 2878 2804 2760 Total 4878 4672 4600 Ethnicity African-American 2780 2522 2484 American Indian or Alaska Native 5 5 5 Asian 5 5 5 Caucasian 1268 1354 1334 Native Hawaiian or other Pacific Islander 5 5 5 Other: specify Clients identified as Multi-racial 278/246 313/270 307/267 Total In our system, Latinos counted separate - not within ethnicity categories Of the above, how many Hispanic/Latino 537 468 468 Of the above, how many non-Hispanic/Latino 4341 4204 4140 Total 4878 4672 4600 Age 0-5 years 0 0 0 6-18 years 49 47 46 19-50 years 2878 2756 2714 51+years 1951 1869 1840 Total 4878 4672 4600 Geographic Location Alamance County 20 15 15 Chatham County 100 95 95 Durham County 100 95 95 Wake County 20 15 15 Orange County Breakdown Chapel Hill Public Housing DK DK DK Town of Chapel Hill (Non-Public Housing) 3268 3036 2990 Town of Carrboro 1220 1214 1196 Town of Hillsborough DK DK DK City of Mebane (Orange County) DK DK DK Orange County(Outside Municipalities) 4585* 4344 4278 *Includes Chapel Hill,Carrboro,Hillsborough,Mebane **missing numbers re people that PROGRAM INFORMATION 1/31/2017 11:43:55 AM Page 21 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION reported as homeless or stranded Total 4878 4672 4600 Work Statement z) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART(Specific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program FoodFirst 3. Program Activity Name Food Programs: Food Pantry Program Goal The Food Pantry will collect or purchase enough non- perishable food items to provide groceries as often as once per month to member households Performance Measures Community Services Director and Client Services Reps track number of bags of groceries and holiday dinners distributed Previous Year Program Results 13,393 bags of groceries and 773 holiday dinners Current Year Estimated Results 12,744 bags of groceries and 786 holiday dinners Next Year Projected Results 12,500 bags of groceries and 700 holiday dinners 4. Program Activity Name Food Programs: Community Kitchen Program Goal A hot, nutritious meal will be served to homeless residents and any hungry person who shows up at mealtimes at the Community Kitchen Performance Measures Kitchen Coordinator determines number of meals served by counting trays at the end of each meal service Previous Year Program Results 38,611 hot meals PROGRAM INFORMATION 1/31/2017 11:43:55 AM Page 25 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Current Year Estimated Results 41,248 hot meals Next Year Projected Results 40,000 hot meals PROGRAM INFORMATION 1/31/2017 11:43:55 AM Page 26 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION aa) Program Budget 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? 38%% 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 725,068 390,971 381,124 Total # of Individuals 4,878 4,672 4,600 Cost Per Individual $149 $84 $83 PROGRAM INFORMATION 1/31/2017 11:43:55 AM P g 2 / of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Support Circles Program Primary Contact and Title: Kristin Lavergne, Community Services Director Telephone Number: 919-929-6380, x41 E-Mail: klavergne@ifcmailbox.org bb)Indicate the type of Human Service Needs Priority, if program applicable: X Priority Area #1: safety-net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents cc) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education Family Resources X X X X Jobs/Jobs Training Food Transportation Other: Please specify dd)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. • Active participation on Orange County's Family Success Alliance leadership council. The Alliance seeks to improve the lives and opportunities for long term success for children and families struggling to make ends meet. This is done through developing a "pipeline" of coordinated community resources that will ensure the successful passage of children from cradle to career or college; • Collaboration with at least 10 faith communities and 1 other group of individual participants to create Circles • IFC works closely with the Community Empowerment Fund which offers financial education, matching funds savings accounts and job search help to many of our Support Circle participants; • Partnership with The Furniture Project, organized by St. Thomas More volunteers and supported by the IFC since its inception, which helps furnish homes for graduates of IFC PROGRAM INFORMATION 1/31/2017 11:43:55 AM Page 2 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION residential services and others throughout the community who might not otherwise have furniture; Program Description (3 pages OR LESS) Please provide the following information about the proposed program: ee)Summarize the program services proposed and how the program will address a Town/County priority/goal? Research shows that as homeless individuals and families transition out of shelters and other emergency housing into more independent living in the community, having support services is an essential component of successful stabilization. A much higher percentage of those who receive wrap-around services remain housed on a more permanent basis. In collaboration with social service agencies, the Support Circles Program contributes to breaking the cycle of poverty and homelessness in Orange County by training and supporting community members (volunteers) to provide material, practical, financial and relational support to those who are transitioning. Each individual or family (called a Partner) is matched with a Support Circle for 12 months. Modeled in large part after the Raleigh /Wake Support Circles Program for Homeless Families. Support Circles provides volunteers essential training to be able to foster relationships that are empowering and offer support with the end goal of enhancing the likelihood that the Partners will be able to sustain the positive changes in their lives, both on an individual level (addressing domestic violence, mental illness and addiction issues) and in facing the structural and systemic challenges that contributed to their homelessness (such as lack of affordable housing, poverty and lack of affordable health care). By providing the support formerly homeless individuals need the hope is to prevent a relapse back into homelessness. The Chapel Hill Human Services Need Assessment lists Education & Family Supports and Resources as an important community need. According to stakeholders, the community lacks sufficient financial resources for organizations helping families in greatest need of support. IFC currently has a half-time Support Circles Coordinator position, which is partially funded by the Human Services grant. Support of this position is "improving access to services and community engagement while addressing the human service needs in Chapel Hill" as each circle engages 8-10 community members to encourage the household moving from homeless to housed, much of which involves problem-solving as issues arise and helping locate resources that may be helpful to the household in being able to maintain their independence. IFC had 8 Support Circles functioning over the course of FY 15-16. This program has grown large enough that an all-volunteer effort is no longer practical. Their success is encouraging other volunteers to come forward and want to form circles, but there is a great deal of training and coordinating that must happen in order to increase the number of circles going at the same time. ff) 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. PROGRAM INFORMATION 1/31/2017 11:43:55 AM Pago 29 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION The 2015-2020 Consolidated Plan states that there is a need for housing and support services for homeless persons, and persons who are at risk of becoming homeless and made HOMELESS PRIORITY a High Priority. The Support Circles program helps meet both HO-2 Operation/Support and HO-3 Prevention and Housing Goals/Strategies as the program provides support to those transitioning out of homelessness into independent living, with the goal of preventing a return to homelessness. gg)Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? We serve the area's formerly homeless. As difficult as it might be to come into a residential facility, there is a sense of connection and community that develops for most. When the time comes to transition out of the facility to independent living, it can be challenging and a sense of isolation can develop. The Support Circles Program can help mitigate this sense of isolation by providing different types of assistance as households transition out of temporary housing situations. hh)Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) One of our Client Services Coordinator dedicates half of her time to carrying out program activities at 110 West Main Street Carrboro. She has a Bachelors degree in Psychology and several years of experience working with homeless and low income populations. She. along with two well-seasoned volunteers comprise the leadership team. ii) Describe the specific period over which the activities will be carried out and include an implementation timeline. The activities will be carried out over the next fiscal year. A family is supported for up to a one year period. New circles are created as interest by a new group arises or when a group that has done a circle states they wish to do another. jj) 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) IFC is one of only a few organizations providing safety-net services in our community. Keeping households from returning to homelessness is a primary goal. The less disruption they experience, the more likely they can move to be fully contributing members of the Chapel Hill/Carrboro community. kk) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. IFC agreed to house the Support Circles program when it became apparent that to maintain and grow the program, a staff position was needed. Continued support is crucial for IFC to be able to continue to house the program. II) Include any other pertinent information. PROGRAM INFORMATION 1/31/2017 11.43.55 AM Pago 30 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Proclram Information mm) Target Population (see previous table for Food Programs and Support Circles) Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male Female Total Ethnicity African-American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Clients identified as Multi-racial Total Of the above, how many Hispanic/Latino Of the above, how many non-Hispanic/Latino Total Age 0-5 years 6-18 years 19-50 years 51+years Total 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) PROGRAM INFORMATION 1/31/2017 11:43:55 AM Pago 31 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement nn)Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART(Specific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program Residential Services 5. Program Activity Name Support Circles Program Goal Support Circles will function as a support system for a formerly homeless individual or family transitioning into permanent housing Performance Measures Number of new and active Circles Previous Year Program Results 3 new, 8 active over the course of the year Current Year Estimated Results 5 new, 6 active Next Year Projected Results 5 new, 6 active 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 oo)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: PROGRAM INFORMATION 1/31/2017 11:43:55 AM Pago 32 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • 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? % 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 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program 53,314 28,748 28,037 Total # of Individuals 8 circles 6 circles 6 circles Cost Per Individual $6664 $4791 $4673 PROGRAM INFORMATION 1/31/2017 11.43.55 AM Pago 33 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Food For the Summer Program Primary Contact and Title: Kristin Lavergne, Co-Director Telephone Number: 919-929-6380 x41 E-Mail: klavergne @ifcmailbox.org a) 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 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) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education X Family Resources Jobs/Jobs Training Food 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. • Town of Chapel Hill • Food For All (UNC) • Town of Carrboro • The Friday Center • Orange County • Book Harvest • NC Department of Public • YMCA of the Triangle Instruction • Food Bank of Central & Eastern • No Kid Hungry NC North Carolina • PORCH • TABLE Program Description (3 pages OR LESS) Please provide the following information about the proposed program: PROGRAM INFORMATION 2/9/2017 10:30:46 AM Page I f 1 0 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Summarize the program services proposed and how the program will address a Town/County priority/goal? Food For the Summer provides nutritious weekday meals at walkable sites throughout the district to children under 18 for the full summer break. Meals are prepared in several CHCCS school cafeterias by cafeteria staff and distributed by a network of volunteers. In addition to daily meals, Food For the Summer offers opportunities for enrichment which help alleviate the "Summer Slide" experienced by many children over the summer. Enrichment opportunities include: • Fun Buckets: Buckets filled with sidewalk chalk, jump ropes, frisbees, games and more are brought to the sites daily to provide opportunities for outside play. • Free Book Wednesdays: With the help of Book Harvest, free books are available for children to take home each week. • Pop-In Guests: Occasional visits from special guests like the local fire and police departments provide children with an opportunity to learn about health, safety and community. • Enrichment Opportunities: Arts & Crafts, Nutrition Activities and more are provided by volunteer organizations. Community Engagement opportunities: Last year, Food For the Summer engaged more than 650 community volunteers, including a significant number of youth volunteers. This year, we will be adding a Teen Ambassador program to provide leadership training and job skills to middle and high school students who live within the impacted communities. Their duties will include planning and participating in meal site events and surveying local kids to gauge the success of the program. Meeting Town and County Goals: The Food For the Summer program addresses the widening problem of summertime food insecurity which will affect 3,400+ children during the eleven week summer break. In addition, the program provides literacy, cultural enrichment and recreational opportunities — all of which add up to healthier children and better academic outcomes. Last summer we provided 48,145 meals and 3,500 free books to children living in Chapel Hill, Carrboro and Orange County. This year, we expect to increase these numbers. d) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and riorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. The Food For the Summer program addresses several items identified in the Human Services Needs Assessment including: PROGRAM INFORMATION 2/9/2017 10:30:46 AM Page 2 • f 1 0 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • Providing healthy meals to children and youth at no charge on weekdays throughout the summer break • Providing free activities that positively engage children and youth from at-risk and low- income households e) 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 the 3,400 children and youth in the CHCCS district who qualify for Free & Reduced Lunch. We use "heat maps" provided by the school district to identify meal sites that are walkable for identified populations. We do outreach through school social workers, community partners (IFC, PORCH, TABLE), and through the town's Housing & Human Services communication channels. We display posters in healthcare clinics and public places throughout Chapel Hill & Carrboro and send home flyers, translated in numerous languages, in children's backpacks as well as in PORCH donation bags. t) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Menu planning and food preparation are overseen by Liz Cartano, Director of Dining for Chapel Hill- Carrboro City Schools; Program Director: We are in the process of hiring a summer-time program director. Last year's director, Katie Hug, had a Masters in Social Work. Candidates for the position tend to have their MSW or experience in education (teachers or teachers' aides); Site Coordinators: We are in the process of hiring this year's Site Coordinators. Candidates are, typically, undergraduate and graduate students at UNC. The Program Director and Site Coordinators will undergo extensive training with former Program Director, Katie Hug. A manual has been written and is provided to each. Volunteers participate in a two hour orientation. g) Describe the specific period over which the activities will be carried out and include an implementation timeline. February: Interviews and hiring of Program Director, Site Coordinators Meeting with Social Workers to provide information on program March-May: Site identification and certification Kick-off event; Participation in community events (Touch-A-Truck; Summer Reading Launch) Staff training; Volunteer orientations June —Aug: June 12 — First day of weekday meal service Early July—JumpStart Carnival (Hargraves Community Center) Wednesdays — "Free Book Wednesdays" PROGRAM INFORMATION 2/9/2017 10:30:46 AM Page 3 • .f 1 0 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Pop-in guests/enrichment programs weekly August 25— Final day of summer meal service h) 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) Food for the Summer is a tremendous investment for the town for several reasons: Food For the Summer provides meals and enrichment opportunities in locations that are walkable for hundreds of Chapel Hill and Carrboro families and children; The program utilizes federal USDA Summer Meals funding to cover food and meal preparation costs, which brought an additional $75,000+ (beyond summer school meals) into our community last year; The program extends summer-time employment for cafeteria workers at three schools for the entire ten week summer as opposed to the limited 2 —3 weeks of summer school; The program provides summer-time employment opportunities for teen-aged and college student; The program provides flexible, rewarding volunteer opportunities for families and teens; The program connects children with public safety workers through lunch-time visits from the fire department and police i) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Our grant request is intended to fund stipends and mentorship opportunities for participants in the new Food For the Summer Teen Ambassador program who come from low-income families. Without that funding, teens will be asked to volunteer their time and we will not be able to run the "special" activities: and learning opportunities we have planned for them. j) Include any other pertinent information. In order to qualify for federal funds, Food For the Summer meal sites were, predominantly, "Open Sites" where children were not required to register. As a result, information about race and ethnicity is not available. 2016 Meal Sites included a mix of public housing, non-public housing, community centers and parks including: Airport Gardens, Carolina Apts, Chase Park Apts, Eastwood, Elliott Woods, Estes Park Apts, Hargraves gazebo; Kingswood Apts, Rainbow Heights, Rigsbee Mobile Home Park, Rogers Road, Royal Park Apts, South Estes, Trinity Court In addition, volunteers also delivered meals to three camp programs: Rogers Road, Teen Center and Hargraves. We anticipate, based on CHCCS heat maps, that with increased outreach and the help of the Teen Ambassador program, we will be able to reach significantly more children at several existing meal sites, including the Hargraves Center and many of the large apartment complexes. While we specifically target children in the CHCCS district, we also reach out through local Preschool programs to ensure that area families with younger children who are not currently in the school system are aware that the program is available and open to them. Additional Program Information PROGRAM INFORMATION 2/9/2017 10:30:46 AM Page 1 • f 1 0 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION k) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Please note: The numbers listed below reference typical daily attendance at each meal site which, because of their open nature, does not represent the total number of children who received services over the course of the summer. Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male Female * Total 0 0 0 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 80 6-18 years 220 19-50 years 51+ years Total 0 301 450 Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing 79 119 Town of Chapel Hill (Non-Public Housing) *127 190 Town of Carrboro 65 87 Town of Hillsborough 0 0 City of Mebane(Orange County) 0 0 PROGRAM INFORMATION 2/9/2017 10:30:46 AM Page 5 • . DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Orange County(Outside Municipalities) 30 30 Total 0 301 426 Work Statement I) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART(Specific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program: Food For the Summer 1. Program Activity Name Food For the Summer Meal Service Program Goal To provide healthy lunches on weekdays to children and youth in the CHCCS system who qualify for Free & Reduced Lunch throughout the entire summer break. Performance Measures Number of meal sites; Number of days served; Number of meals served; Number of volunteers engaged; Previous Year Program Results Current Year Estimated Results Meal Sites: 15 Days Served: 54 Total Meals Served: 48,145 Volunteer-delivered meals: 24,512 Volunteers engaged: 650+ Volunteer slots filled: 1,748 Next Year Projected Results Meal Sites: 15—20 Days Served: 54 Total Meals Served: 55,000 Volunteers engaged: 650—700 Volunteer Slots: 1,748—2,000 2. Program Activity Name Food For the Summer— Literacy& Enrichment Program Goal To provide enrichment opportunities at meal sites Performance Measures #programs offered Previous Year Program Results Current Year Estimated Results Primarily volunteer driven; Fun buckets available daily at every site Distributed 3,500 books on "Free Book Wednesdays" Visits from police &fire department, Kidzu at a few sites PROGRAM INFORMATION 2/9/2017 10:30:46 AM Page 6i DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Next Year Projected Results Literacy& Enrichment Committee planning Fun buckets available daily Free Book Wednesdays will continue Enrichment opportunities twice per week at each site Promotion of Librar 's Summer Readin. Challen.e 3. Program Activity Name Teen Ambassador program Program Goal To provide leadership opportunities and job skills to teens living in low-income neighborhoods that are served by FFTS Performance Measures #Ambassadors, Mentorship program offerings Survey of teens during course of summer Previous Year Program Results NA Current Year Estimated Results NA Next Year Projected Results 4—6 Ambassadors Will provide orientation, periodic get-togethers for mentoring Duties will include helping to plan and implement enrichment activities; survey children during summer to assess engagement; assist with outreach 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 10:30:46 AM Page DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION m) 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? n/a% Food for the Summer is a self-standing program carried out by community collaboration that includes the IFC. IFC is acting as fiscal agent. 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 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program $18,000 $22,000 Total # of Individuals 301 350 (Summer 2016) (Summer 2017) Cost Per Individual $60 $63 PROGRAM INFORMATION 2/9/2017 10:30:46 AM Page f 1 0 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2015, for calendar year agencies, and FY 2015-16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit/report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2014 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990-N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Frequently Asked Questions Guide ( F), about exemptions. If exempt per N.C.G.S. § 131 F-3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax-Exemption Letter A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 — June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. DO NOT SUBMIT THIS PAGE 2/9/2017 10:30:46 AM I:' 9 t °f DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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 $2 million Aggregate Injury Property $2 million Aggregate Damage Limit Automobile Not Applicable $1 million Each Occurrence $500,000 Each Liability Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts 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 10:30:46 AM Page 10 t t DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XH I 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 (P F), about exemptions. If exempt per N.C.G.S. § 131 F-3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax-Exemption Letter A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 — June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. DO NOT SUBMIT THIS PAGE 1/31/2017 11.43.55 AM P a g e 31 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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 Occurrence $1 million Each Liability $1,000,000 Bodily $2 million Aggregate Occurrence Injury and Property $2 million Aggregate Damage Limit Automobile Not Applicable $1 million Each Occurrence $500 000 Each Liability Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts webpae 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 1/31/2017 11:43:55 AM P g c 35 of 35 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Section III. Program Information Agency Budget Worksheet AGENCY NAME: Inter-Faith Council for Social Service Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 3,488,764 $ 838,246 $ 838,246 0% Program Generated Revenue(fees) $ 43,903 $ 34,868 $ 34,868 0% Local Government Grants: Orange County $ 44,000 $ 50,000 $ 50,000 0% Town of Chapel Hill $ 19,000 $ 25,000 $ 25,000 0% Town of Carrboro $ 10,000 $ 11,950 $ 11,950 0% Other Local: --- 0 Other Local: --- 0 Other Local: --- 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 113,596 $ 124,301 $ 124,301 0% State Government $ - $ - $ - 0 Federal Government $ - $ - $ - 0 Other Grants Foundations $ 260,779 $ 278,599 $ 278,599 0% Other Grants Access To Recovery $ 76,800 $ 76,800 0% Miscellaneous/Other Revenue $ 205,500 $ 477,161 $ 477,161 0% Please list 3 largest Miscellanous sources: Endowment Inc $ 301,617.00 Events $ 111,677.00 CDBG $ 12,832.00 Total Program Revenue $ 4 185 542 $ 1 916 925 $ 1 916 925 0% PROGRAM EXPENSES Compensation $ 1,231,078 $ 1,342,205 $ 1,382,471 3% Rent&Utilities $ 50,476 $ 58,869 $ 60,635 3% Supplies& Equipment $ 48,169 $ 26,400 $ 26,400 0% Travel &Training $ 805 $ 500 $ 500 0% Other Expenses: $ 2,223,728 $ 488,551 $ 446,919 -9% Please list 3 largest"Other Expenses": Crisis Intervention Program $ 119,804.00 Professional Fees $ 96,420.00 Food $ 51,500.00 Total Program Expenses $ 3 554 256 $ 1 916 525 $ 1 916 925 0% SURPLUS/(DEFICIT) FOR PERIOD: $ 631,286 I $ 400 I $ - I -100% FY 2015-16 Program Budget Revised 9/29/2014 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Section III. Program Information Program Budget Worksheet AGENCY NAME: Inter-Faith Council for Social Service - Residential Services Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 1,897,888 $ 456,006 $ 456,006 0% Program Generated Revenue(fees) $ 23,883 $ 18,968 $ 18,968 0% Local Government Grants: Orange County $ 31,240 $ 35,500 $ 35,500 0% Town of Chapel Hill $ 13,490 $ 17,750 $ 17,750 0% Town of Carrboro $ 7,100 $ 8,485 $ 8,485 0% Other Local: --- 0 Other Local: --- 0 Other Local: --- 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 61,796 $ 67,620 $ 67,620 0% State Government $ - $ - $ - 0 Federal Government $ - $ - $ - 0 Other Grants Foundations $ 141,864 $ 151,558 $ 151,558 0% Other Grants Access To Recovery $ - $ - $ - 0 Miscellaneous/Other Revenue $ 111,792 $ 259,576 $ 259,576 0% Please list 3 largest Miscellanous sources: Endowment Inc Events CDBG Total Program Revenue $ 2 289 053 $ 1 015 463 $ 1 015 463 0% PROGRAM EXPENSES Compensation $ 669,706 $ 730,160 $ 752,065 3% Rent&Utilities $ 27,459 $ 32,025 $ 32,986 3% Supplies& Equipment $ 26,204 $ 14,362 $ 14,793 3% Travel &Training $ 438 $ 272 $ 272 0% Other Expenses: $ 1,209,708 $ 265,772 $ 215,348 -19% Please list 3 largest"Other Expenses": Crisis Intervention Program Professional Fees Food Total Program Expenses $ 1 933 515 $ 1 042 591 $ 1 015 463 -3% SURPLUS/(DEFICIT) FOR PERIOD: $ 355,538 I $ (27,128)1 $ (0)1 100% FY 2015-16 Program Budget Revised 9/29/2014 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Section III. Program Information Program Budget Worksheet AGENCY NAME: Inter-Faith Council for Social Service - Food Programs Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 711,708 $ 171,002 $ 171,002 0% Program Generated Revenue(fees) $ 8,956 $ 7,113 $ 7,113 0% Local Government Grants: Orange County $ 11,880 $ 13,500 $ 13,500 0% Town of Chapel Hill $ 5,130 $ 6,750 $ 6,750 0% Town of Carrboro $ 2,700 $ 3,227 $ 3,227 0% Other Local: --- 0 Other Local: --- 0 Other Local: --- 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 23,174 $ 25,357 $ 25,357 0% State Government $ - $ - $ - 0 Federal Government $ - $ - $ - 0 Other Grants Foundations $ 53,199 $ 56,834 $ 56,834 0% Other Grants Access To Recovery $ - $ - $ - 0 Miscellaneous/Other Revenue $ 41,922 $ 97,341 $ 97,341 0% Please list 3 largest Miscellanous sources: Endowment Inc Events CDBG Total Program Revenue $ 858 669 $ 381 124 $ 381 124 0% PROGRAM EXPENSES Compensation $ 251,140 $ 273,810 $ 282,024 3% Rent&Utilities $ 10,297 $ 12,009 $ 12,369 3% Supplies& Equipment $ 9,826 $ 5,386 $ 5,386 0% Travel &Training $ 164 $ 102 $ 102 0% Other Expenses: $ 453,641 $ 99,664 $ 81,242 -18% Please list 3 largest"Other Expenses": Crisis Intervention Program Professional Fees Food Total Program Expenses $ 725 068 $ 390 971 $ 381 124 -3% SURPLUS/(DEFICIT) FOR PERIOD: $ 133,601 I $ (9,847)1 $ 0 1 100% FY 2015-16 Program Budget Revised 9/29/2014 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Section III. Program Information Program Budget Worksheet AGENCY NAME: Inter-Faith Council for Social Service - Residential Services Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 52,331 $ 12,574 $ 12,574 0% Program Generated Revenue(fees) $ 659 $ 523 $ 523 0% Local Government Grants: Orange County $ 880 $ 1,000 $ 1,000 0% Town of Chapel Hill $ 380 $ 500 $ 500 0% Town of Carrboro $ 200 $ 239 $ 239 0% Other Local: --- 0 Other Local: --- 0 Other Local: --- 0 If more than 3 sources,please provide a separate list. Non-Local Government Grants Triangle United Way $ 1,704 $ 1,865 $ 1,865 0% State Government $ - $ - $ - 0 Federal Government $ - $ - $ - 0 Other Grants Foundations $ 3,912 $ 4,179 $ 4,179 0% Other Grants Access To Recovery $ - $ - $ - 0 Miscellaneous/Other Revenue $ 3,083 $ 7,157 $ 7,157 0% Please list 3 largest Miscellanous sources: Endowment Inc Events CDBG Total Program Revenue $ 63 149 $ 28 037 $ 28 037 0% PROGRAM EXPENSES Compensation $ 18,466 $ 20,133 $ 20,737 3% Rent&Utilities $ 757 $ 883 $ 909 3% Supplies& Equipment $ 723 $ 396 $ 396 0% Travel &Training $ 12 $ 8 $ 8 0% Other Expenses: $ 33,356 $ 7,328 $ 5,987 -18% Please list 3 largest"Other Expenses": Crisis Intervention Program Professional Fees Food Total Program Expenses $ 53 314 $ 28 748 $ 28 037 -2% SURPLUS/(DEFICIT) FOR PERIOD: $ 9,835 I $ (711)1 $ (0)1 100% FY 2015-16 Program Budget Revised 9/29/2014 Fn - r1 fnr the Cumma r Program IFC DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C PROVIDER'S OUTSIDE AGENCY APPLICATION Actual Estimate Projected Percent PROGRAM REVENUE 2015-16 d 2016-17 2017-18 Change Private Donations $ - $ 3,200 $ 4,000 25% Program Generated Revenue(fees) $ - $ 468 $ 6,000 1182% Local Government Grants: Orange County $ - $ 1,500 0 Town of Chapel Hill $ - $ 1,500 0 Town of Carrboro $ - $ 1,500 0 Other Local: --- 0 Other Local: --- 0 Other Local: --- 0 a separate list. Non-Local Government Grants Triangle United Way ---- State Government $ - $ 5,000 $ - -100% Federal Government $ - $ - $ - 0 Other Grants: Foundations $ 8,300 $ 6,000 -28% Other Grants: Access To Recovery $ - $ - $ - 0 Miscellaneous/Other Revenue $ - $ - 0 Please list 3 largest Miscellanous sources: Endowment Inc Events CDBG Total Program Revenue $ - $16 968 $20 500 21% PROGRAM EXPENSES Compensation $ 16,000 $ 19,000 19% Rent&Utilities $ - 0 Supplies&Equipment $ 2,000 $ 3,000 50% Travel&Training $ - 0 Other Expenses: $ - 0 Please list 3 largest"Other Expenses": Crisis Intervention Program Professional Fees Food Total Program Expenses $ - $18 000 $22 000 22% SURPLUS/(DEFICIT)FOR PERIOD: $ - $ (1,032)1 $ (1,500)1 -45% DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C EXHIBIT "B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Inter-Faith Council for Social Service Program Name: Food Programs Funding Award: $22,500 Outline how the agency will spend Orange County's funding award. Expense Description Amount Program Staff $22,500 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • The Food Pantry will collect or purchase enough non-perishable food items to provide groceries as often as once a month to member households. • A hot, nutritious meal will be served to homeless residents and any hungry person who shows up at mealtimes at Community Kitchen. 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 bags of groceries distributed through the Pantry 12,500 Number of meals served through the Community Kitchen 40,000 DocuSigned by: s) S Executive Director 10/16/2017 B617305AEFF04A9... Certified by 'Yj , Title: CO OVt-VV lA/1,4 tc--) Date: 12 i 07- (Provider's Signature) ,4-07vLe-g � �� DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C EMIIBIT "13" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Inter-Faith Council for Social Service Program Name: Support Circles Funding Award: $1,500 Outline how the agency will spend Orange County's funding award. Expense Description Amount Program Staff $1,500 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. o Support Circles will function as a support sysytem for a formerly homeless individual or family transitioning into permanent housing 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 new and active circles 5,6 DocuSigned by: �Gt(�clt, ,)t IIS Executive Di rector 10/16/2017 B61773055AEEFF04A9... -y Certified by�' � C 2 Title: C�i +c c.i Date: 7 12-4 f i (Provider's Signature s°-er--f-/vc-c S b dV-.o DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C EXHIBIT"B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Inter-Faith Council for Social Service Program Name: Residential Services Funding Award: $26,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Program Staff $26,000 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Community Hosue and HomeStart will provide safe, emergency shelter and transitional housing, as well as Case Management to reduce obstacles to overcoming homelessness 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 homeless persons that receive shelter,with access to Case Management Services 343 O DocuSigned by: i� ^US 10/16/2017 J Executive Director B617305AEFF04A9... Certified.by: 4 Title: C - -�-�-^y � Date: 94 2 f ( f Provider's Signa� 0.4 cry DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C 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: �a G�cit, ,)uAls B617305AEFF04A9... Executive Di rector 10/16/2017 Certified by: Title: Date: (Provider's Signature) (Inter-Faith Council for Social Service) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7/17 DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C ____.-.""1 INTECOU-01 KDAVIS ACORO"° CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) ki..• 07/13/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Kelly Davis NAME: Summers Thompson Lowry,Inc. PHONE FAX 100 Europa Drive (A/c,No,Ext): (919)904-7295 (A/C,No):(919)942-4221 Suite 571 aooRlEss:kelly@stlinsure.com Chapel Hill,NC 27517-2393 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Alliance for Non-Profits for Insurance Risk Retention Group INSURED INSURER B:Association Insurance Company Inter-Faith Council for Social Service Inc. INSURER C:Hartford Fire Insurance Company 19682 110 W. Main Street INSURER D:The Hanover Ins Co 22292 Carrboro,NC 27510 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 TYPE OF INSURANCE ADDL SUBR W POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD VD (MM/DD/YYYY) (MM/DD/YYYY) A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 2016-17838 07/01/2017 07/01/2018 DAMAGETO RENTED 500,000 X PREMISES(Ea occurrence) $ X Professional 1 M/2M MED EXP(Any one person) $ 20,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO 2016-17838 07/01/2017 07/01/2018 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ AUTOS ONLY NON-OWNED ONLYY PROPERTY DAMAGE $ (Per PROPERTY $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE X 2017-17838-UMB 07/01/2017 07/01/2018 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ B WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N WC522-000320-115 07/01/2017 07/01/2018 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Crime/ERISA 22BDDHK5511 07/01/2017 07/01/2018 100,000 D D&O/Employment Pract LH68785106 07/01/2017 07/01/2018 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) It is understood and agreed that the certificate holder is included as additional insured as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE a County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Oran g ty ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough,NC 27278 AUTHORIZED REPRESENTATIVE gof,,,,,Pt S r, r„ .m.5 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID:64D61581-25C0-4408-84C2-991109E2DF4C POLICY NUMBER: 2016-17838 COMMERCIAL GENERAL LIABILITY CG 20 26 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Any person or organization that you are required to add as an additional insured on this policy, under a written contract or agreement currently in effect, or becoming effective during the term of this policy. The additional insured status will not be afforded with respect to liability arising out of or related to your activities as a real estate manager for that person or organization. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II—Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s)or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III— Limits Of Insurance: with respect to liability for"bodily injury', "property damage"or"personal and advertising injury" If coverage provided to the additional insured is caused, in whole or in part, by your acts or required by a contract or agreement, the most we omissions or the acts or omissions of those acting will pay on behalf of the additional insured is the on your behalf: amount of insurance: 1. In the performance of your ongoing operations; 1. Required by the contract or agreement; or or 2. Available under the applicable Limits of 2. In connection with your premises owned by or Insurance shown in the Declarations; rented to you. whichever is less. However: This endorsement shall not increase the 1. The insurance afforded to such additional applicable Limits of Insurance shown in the insured only applies to the extent permitted by Declarations. law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1