HomeMy WebLinkAbout2017-604 Co. Mgr. - NC Dept. of Agriculture and Consumer Services for the Orange County Crop Fund B. e i
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Steve Troxler North Carolina Department of Agriculture N. David Smith
Commissioner and Consumer Services Chief Deputy Commissioner
March 9, 2017
Ms. Bonnie Hammersly County Manager
Orange County
200 South Cameron Street
Hillsborough, NC 27278
ACCEPTANCE OF AWARD NOTIFICATION
Dear Ms. Hammersly:
On behalf of Commissioner Steve Troxler and the NC Department of Agriculture and Consumer Services, we
are pleased that you have accepted the Department's offer of$32,500.00.
By accepting our offer of financial assistance, you have agreed to the specific stipulations, terms and
conditions, and reporting requirements contained in the Contract that you signed. Enclosed is a fully
executed Contract for your records.
The forms listed below are used to fulfill the departmental reporting requirements of the North Carolina
Agricultural Development and Farmland Preservation Trust Fund. They may also be downloaded from our
website at www.ncadfp.org.
1. General Instructions
2. Initial Request for Payment/Request for Reimbursement
3. Progress Report
4. Budget Report
5. Equipment Inventory/In-Kind Summary
6. Initial Payment Documentation
If you have any questions regarding the Contract, please feel to contact Veronica Jamison at 919-707-3071
or by email at veronica.jamison @ncagr.gov.
ncer
Davi mith `
Chief Deputy Commissioner
Enclosures
cc: Kathryn L. Caler, M.L.S., Grants& Contracts Administrator
Email: David.Smith @ncagr.gov
1001 Mail Service Center,Raleigh, North Carolina,27699-1001
(919)707-3033• Fax(919)715-0026
An Equal Opportunity Affirmative Action Employer
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Steve Troxler North Carolina Department of Agriculture N. David Smith
Commissioner and Consumer Services Chief Deputy Commissioner
November 23, 2016
Ms. Bonnie Hammersly County Manager
Orange County
200 South Cameron Street
Hillsborough, NC 27278
NOTIFICATION OF FUNDING OFFER
Dear Ms Hammersly:
On behalf of Commissioner Steve Troxler and the North Carolina Department of Agriculture and Consumer
Services—Farmland Preservation, I am pleased to inform you that$32,500.00 for your project, Orange
County Crop Fund, was approved under the North Carolina Agricultural Development and Farmland
Preservation Trust Fund.
Two original Contract packets must be completed and returned to the NCDA&CS, making sure that the
Contracts and certain forms have been signed, dated, and witnessed, as applicable, before they are returned
to the address provided in your Contract cover document. By completing these documents, you are agreeing
to the specific stipulations, the general terms and conditions, and specific reporting requirements.
All authorized representative signatures must be in blue ink. Use the Contract Check off List to ensure all
attachments are included and are in the correct order for each Contract Packet.
One fully executed, original Contract will be returned to you for your records. If you have any questions about
your Contract or any of the forms contained in your offer packet, please call Veronica Jamison at 919-707-
3071, or feel free to send an email to veronica.jamison @ncagr.gov.
I would like to take this opportunity to thank you for participating in the North Carolina Agricultural
Development and Farmland Preservation Trust Fund, which has been established to promote profitable and
sustainable agriculture, conservation agreements n agriculturTI conservation easements.
'Sin erely,
i
r
V
N. David Smith
Chief Deputy Commissioner
Enclosures
cc: Kathryn L. Caler, M.L.S., Grants &Contracts Administrator
Email: David.Smith @ncagr.gov
1001 Mail Service Center, Raleigh, North Carolina,27699-1001
(919)707-3033• Fax(919)715-0026
An Equal Opportunity Affirmative Action Employer
REQUEST TO ADFP TRUST FUND FOR APPROVAL OF SUBCONTRACTING
GRANTEE: c.i
Contract# : M e(
Pursuant to the General Terms and Conditions of the Contract*between the Grantee and the
Agency, Grant a here4y reques s a roval of the attached contract between Grantee and (subcontractor)
SA t' .� ,. ._T 14M, to assist in carrying out the purposes of the above-
referenced contract.
Date: 17
Gra tee,Authorized Repr se tive
Approved: %;,,,. `" kQ,( Date:
Dewitt Hardee
This grant and the subsequent revolving loan fund is intended to provide seasonal funding to clients of
the Piedmont Food and Agricultural Processing (PFAP)facility in Hillsborough, NC who purchase NC
Grown farm products for their value-added products.
The intent of this subcontracting request is to notify the Agency that matching funds as required by the
Grantee (noted in Section V, part C)will be provided to the Grantee (Orange County) by Weaver Street
Market Cooperative in Hillsborough, NC. These matching funds will not come from tax-funded accounts
in the County budget.
This agreement does not obligate Weaver Street Market(WSM) to agree to fund any loan which it(WSM)
determines to be unsuitable. Further, matching funds may be offered, in lieu of WSM matching, by the
loan applicant.
* Subcontracting: The Grantee shall not subcontract any of the work contemplated under this Contract
without prior written approval from the Agency. Any approved subcontract shall be subject to all
conditions of this Contract. Only the subcontractors or subgrantees specified in the contract documents
are to be considered approved upon award of the contract. The Agency shall not be obligated to pay for
any work performed by any unapproved subcontractor or subgrantee. The Grantee shall be responsible
for the performance of all of its subgrantees and shall not be relieved of any of the duties and
responsibilities of this Contract.
Contract Tracking (Funding from the Department) ADFP Trust Fund Tracking#:ADM-ADFP-16-015
This form should always be the first page of an offer or award package Tracking#: 17-E-088-ADFP
submitted to Grants&Contracts Section for review and processing.The Contract#:t'7-p7 y 4103Y
Grants&Contracts Section will issue the Tracking and Contract numbers. NCGrants ID#:
The Division will add the NCGrants ID#and notify G&C of the ID#. Non Profit, and For Profit Grantees
CONTRACT TRACKING FORM
El Offer Date: 9/ 2016 2Z Award Date:
1. Division: Farmland Preservation
2. Project Leader/Contact: Dewitt Hardee Title: Pro ram Manager Phone: 919-707-3069
Email: dewift.hardee@ncagr.gov
3. Division Contact if different from Project Title: Administrative Officer Phone: 919-707-3071
Leader: Veronica Jamison
Email: veronica.jamison@ncagr.gov
4. CRIS Program Name: Agricultural Development and Farmland Preservation
5. CRIS#: 1256
6. Grantor Name: ADFP Trust Fund
7. Grantor Agreement/Contract#:
8. CFDA#and Fed Program Name:
9. Project Title: Orange County Crop Fund
10. Project Purpose:A revolving loan fund that will enable farmers, producers, and agribusinesses to maintain
viable operations throughout the growing season, and will repay loans at the end of the year.
**If salaries are included in the Contract amount, complete& attach page 1A for tracking purposes**
11. Project Period: October 1, 2016- September 30, 2018
12. County of Primary Service: Orange
13._Type of Contract: Federal Pass Through Z State El Other(Explain)
14. Sub Award Amount: $32,500.00
15. Match Required: Z yes Amount: $32,500.00 no
**For required match, complete&attach Page 1A for tracking purposes
16. Are Indirect Costs Allowable? LJ Yes Z No
**If Yes—written prior approval from Budget& Finance must be obtained and attached
17. Retainage 20 % of Total Contract Award Withheld: $6,500 Z No
"Special Appropriations & Lump Sum < $100,000 or Waiver from Chief Deputy Commissioner on file
18. Equipment in the Amount of$5,000 and Over to be purchased 0 Yes ® No
**If Yes, complete &attach page 1A for tracking purposes
19. Account#: 536406 20. Center#: 2108-1014-2017
21. Grantee Name: Orange Coun 22. Is the Grantee ® New or❑ Existin
23. Grantee Type: Ll Non-Profit Z Governmental Private for Profit LJ Individual
❑ Other (Explain)
24. Grantee Tax ID: 56-6000327 25. Grantee DUNS: 091575191
26. Tax Exempt Status Verified at Guidestar.or or IRS. ov- Initial & Date: 08/4/2017 VJ
27. Federal Debarment Status Verified at SAM.gov—Initial & Date: 11/10/2016
28. Grantee Fiscal Year End: 06/30 29. G.S. State Reporting Due Date:
(Grants &Contracts Section
Offer/Award: L1 Yes 0 No 0 n/a Is the Grantee on the State's"Suspension of Funding List?"
Tax Exempt Status Verified at Guidestar.org or IRS.gov- Initial & Date:
Federal Debarment Status Verified at SAM.gov— Initial & Date:
Attach this page to Page 1A, and/or Page 2 when amending or revising a current Contract, as applicable.
Effective 7/1/07
Rev:7/14
CONTRACT TRACKING(Award FROM Department)-Continuation ADFP Trust Fund Tracking#:ADM-ADFP-16-015
Tracking#:
Contract#:/7—ON—`ff--43 9'
NCGrants ID#:
Total amount awarded for salaries&fringe benefits and/or wages: $
SALARY OR
POSITION TITLE NUMBER OF WORK HOURLY RATE FRINGE TOTAL
HRS EXPECTED OF PAY WAGE BENEFITS
Example: Consultant 60 $100 /h N/A $ 6,000.00
OF COL
IN-KIND MATCH CASH MATCH
CATEGORY AMOUNT AMOUNT
Example: Travel $ 1,000.00
GRAtD ,Ole 'SOF ld:� $
AS
EXPLAIN METHOD FOR TRACKING REQUIRED MATCH
❑ Individual Time Sheets
❑ Salary Registers
❑ Copies of Invoices
❑ Match Certification Statement from Grantee's Chief Financial Officer w/appropriate documentation attached
❑ Bank Deposits(Use of Cash Match Only)
❑ Travel Reimbursement Requests
❑ Other(Itemize Below)
1.
2.
3.
4.
5.
PRIOR APPROVAL OBTAINED $5,000&OVER)
YES NO PENDING DATE ITEM COST
❑ ❑ ❑ $
LIST EQUIPMENT TO BE RETURNED TO DEPARTMENT
ITEM ID#NUMBER CONDITION DATE RECEIVED
Page 1 A—Supplemental
Rev.11/15
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Begin Date:
Completed Date:
NCDA&CS
ADFP Trust Fund
Contract Checklist
Grantee: Orange County
Project Title: Orange County Crop Fund
ADFP Tracking#: ADM-ADFP-16-015
Contract#: /7- 07 ' 1639 NC Grants ID #:
Contract Date :10/1/2016-9/30/2018 Grant Contract Amount: $32,500.00
1. Budget Officer will need to gather the following documents from the grantee's
application and review for accuracy to be placed in the grantee's contract. Items
that are incorrect, the Budget Officer should contact the grantee by phone and
email to inform them of the correct documents needed. The Budget Officer
should make sure all signatures are in BLUE INK.
Initials Date
❑ N/A or ❑ Scope of Work
❑ N/A or ❑ Budget & Budget Narrative
(Budget Officer will need to contact the grantee by phone and email to get the correct
Budget based on the amount approved by the ADFP Trust Fund Advisory Committee).
❑ N/A or ❑ Certification of No Overdue Tax Debts
(Non-Governmental Only)
❑ N/A or ❑ Certification Form and Current Conflict of Interest
(Non-Governmental Only)
❑ N/A or ❑ 501 (C) (3) Certification Form and IRS Federal Tax Exempt
Letter(Non-Governmental Only)
❑ N/A or ❑ Project Timeline
(Budget Officer will need to contact the grantee by phone and email to get the correct
Project Timeline based on the amount approved by the ADFP Trust Fund Advisory
Committee).
❑ N/A or ❑ FPP Acceptance Letter by County (Plan Contracts Only)
❑ N/A or ❑ NC Openbook Supplemental Information
* The Budget Officer shall have above documents checked and completed within 10 working
days of assignment for each group of five. Assignment is triggered by ADFP Trust Fund
Advisory Committee approval and availability of funds to issue the contract.
Edited 08/14/2014 eh
Initials Date
2. Once the Budget Officer has completed the review of documents above
and all documents are correct, the Budget Officer will provide
documents to the Office Manager.
3. The Office Manager will review the Offer Contract for accuracy.
If any part of the contract is not accurate the Office Manager will return the
contract to the Budget Officer for corrections to be made.
4. The Office Manager will complete the Offer Contract
within 5 working days.
5. The Office Manager will submit the Offer Contract to the Grants
and Contract Office for review and signature by Chief
Deputy Commissioner within 5 working days of initial review
provided contract is accurate.
6. The Office Manager will pick up the Offer Contract from the Grants
and Contract Office and complete the following within 2 working days:
❑ Scan in a PDF copy of the Offer Contract
❑ Prepare Offer Contract for Mailing
❑ Mail Offer Contract to grantee
*The grantee is requested to return the offer contract back to the ADFP Trust Fund Office
within 10 working days, but realizes that more time may be needed for the local process.
7. The Office Manager will receive the Offer Contract from the grantee
and stamp in to show date received back on the same day.
8. The Office Manager will review all documents for accuracy and will make sure
all signatures are in BLUE INK within 2 working days.
9. The Office Manager will complete and conduct a final review of the Award Contract,
if everything is correct, the Office Manager will submit the Award Contract to the
Grants and Contracts Office for final signature by the Chief Deputy Commissioner
within 2 working days of completing the award contract.
Edited 08/14/2014 eh
Initials Date
10. The Office Manager will pick up the Award Contract from the
Grants and Contract Office and will complete the following within 5 working
days:
❑ N/A or ❑ Enter grantee into NC Grants and receive a NC Grant
ID # to be placed on the Award Contract
❑ N/A or ❑ Submit the NC Grants ID # obtained to the Grants
and Contracts Office.
❑ Scan in a PDF copy of the Award Contract
❑ Prepare the Award Contract for Mailing
❑ Mail one copy of the Award Contract to the grantee
❑ File one Copy of the Award Contract in the grantee file.
•These steps may vary for unforeseen circumstances. The Office Manger or the
Program Manager will inform ADFP Staff Members of changes as they may occur.
•Specific Due Dates will be provided by Program Manager or Office Manager.
*ATTACH ALL E-MAIL NOTIFICATIONS TO GRANTEE TO BE INCLUDED IN
THEIR FILE FOR DOCUMENTATION PURPOSES.
11. Final Step: Once the contract checklist is completed it must be provided to the
Program Manager for final signature.
Signature of Program Manager Date
(To acknowledge the completeness of the Contract Process)
Edited 08/14/2014 eh
NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES
Steven W. Troxler, Commissioner
NCDA&CS Farmland Preservation - North Carolina Agricultural Development and Farmland Preservation
Trust Fund
CONTRACT "CHECK OFF LIST" for Grantee
INSTRUCTIONS• CHECK THE"YES"BOXES IN LEFT COLUMN FOR THE DOCUMENT TITLES THAT ARE BEING RETURNED WITH THE TWO SIGNED DATED and
WITNESSED COPIES OF THE CONTRACT WITH SIGNATURES IN BLUE INK BE SURE TO INCLUDE ALL THE OTHER DOCUMENTS SPECIFIED IN YOUR CONTRACT
PACKAGE IF "M NO"HAS BEEN CHECKED OFF FOR YOU THAT DOCUMENT IS NOT REOURED FOR THIS GRANT-PROGRAM OR PROJECT.
GRANTEE ORGANIZATION NAME: Orange County
PROJECT TITLE/NAME: Orange County Crop Fund
CONTRACT #: 17- 67y-24)39" TRACKING #: 117
ADFP TRUST FUND TRACKING #: ADM-ADFP-16-015
DEPARTMENTAL GRANTS&
GOVERNMENTAL DOCUMENT TITLE USE- CONTRACTS USE-
ENTITIES ONLY ALL SIGNATURES MUST BE ZN BLUE INK DOCUMENTS DOCUMENTS
Check one Box ATTACHED OR ON ATTACHED
FILE
❑ Yes 0 No Contract"Check Off List"for Grantee Yes ❑ No Yes No
❑ Yes LJ No Contract Cover To be signed, dated &witnessed Yes Ej No Yes ❑ No
❑ Yes C3 No ATTACHMENT A- General Terms&Conditions n Yes n No Yes No
❑ Yes ❑ No ATTACHMENT B - Scope of Work ❑ Yes ❑ No ❑ Yes ❑ No
❑ Yes ❑ No ATTACHMENT C - Budget and Budget Narrative Yes No ❑ Yes No
❑ Yes No ATTACHMENT D - Project Timeline Yes ❑ No ❑ Yes No
❑ Yes No ATTACHMENT E - Owner Maintenance Agreement (Equipment Purchases Only) Yes ❑ No ❑ Yes ❑ No
❑ Yes ❑ No ATTACHMENT F - NCO enbook Supplemental Information ❑ mYesNo Yes No
❑ Yes ❑ No ATTACHMENT G - Performance Measures ❑ Yes No
❑ Yes ❑ No ATTACHMENT H - Certifications and Assurances ❑ ❑ Yes ❑ No
❑ Yes No ATTACHMENT I - Si nature Card El Yes R No Yes No
❑ Yes ❑ No ATTACHMENT J - W-9 Tax Information Yes No Yes No
❑ Yes 0 No ATTACHMENT K -Vendor Electronic Payment Form Yes Fl No Yes Cl No
Effective 11115
STATE OF NORTH CAROLINA -
Departmental Use Only
COUNTY OF WAKE CENTER:2108
ACCOUNT:536E06
AMOUNT:$32,500
North Carolina Department of Agriculture and Consumer Services
Farmland Preservation
North Carolina Agricultural Development and
Farmland Preservation Trust Fund — Cycle IX
Governmental
CONTRACT# C-1-D 7,q" 4034
ADFP Tracking #ADM-ADFP-16-015
This Contract is hereby entered into by and between the North Carolina Department of Agriculture and
Consumer Services, Farmland Preservation — North Carolina Agriculture Development and Farmland
Preservation Trust Fund. (the "Agency") and Orange County, (Grantee), and referred to collectively as the
"Parties".The Grantee's federal tax identification number is 56-6000327 and is physically located in Orange County,
and is further located at 200 South Cameron Street Hillsborough NC 27278.
The purpose of this Contract is to encourage the preservation of qualifying agricultural, horticultural,and forestlands
to foster the growth, development, and sustainability of family farms. The Grantee's project title is Orange County
Crop Fund. This Contract is funded by State appropriations. Funds awarded under this Contract must be used for
the purposes for which they are intended.
The Grantee's fiscal year ends June 30.
I. Contract Documents:
This Contract consists of the Grant Contract and its attachments, all of which are identified by name as follows:
1. This Contract
2. General Terms and Conditions(Attachment A)
3. Scope of Work(Attachment B)
4. Budget and Budget Narrative(Attachment C)
5. Project Timeline(Attachment D)
6. Owner/Maintenance Agreement(Attachment E) (Only for grants purchasing equipment)
7. NC Openbook Supplemental Information(Attachment F)
8. Performance Measures(Attachment G)
9. Certifications and Assurances Section(Attachment H)
10. Signature Card (Attachment 1)
11. W-9 Tax Information (Attachment J)
12. Vendor Electronic Payment Form (Attachment K)
These documents constitute the entire agreement between the Parties and supersede all prior oral or written
statements or agreements.
NCDA&CS(Govt Development Project Contract Cover—State Appropriations Only)Rev. 11115 Page 1 of 7
II. Precedence Among Contract Documents:
In the event of a conflict between or among the terms of the Contract Documents, the terms in the Contract
Document with the highest relative precedence shall prevail. The order of precedence shall be the order of
documents as listed in Paragraph 1, above, with the first-listed document having the highest precedence and
the last-listed document having the lowest precedence. If there are multiple Contract Amendments, the most
recent amendment shall have the highest precedence and the oldest amendment shall have the lowest
precedence.
III. Effective Period:
This Contract shall be effective on October 1,2016 and shall terminate on September 30,2018,with the option
to extend, if mutually agreed upon, through a written amendment as provided for in the General Terms and
Conditions as described in Attachment A.
IV. Grantee's Duties:
The Grantee shall conduct activities as described in Attachment B, Scope of Work, and in accordance with the
approved budget in Attachment C and the approved timeline in Attachment D. In addition, the Grantee shall
complete the activities as specified below.
a. The Grantee shall be responsible for the acquisition of all permits and licenses required in the
performance of the activities as described in the Scope of Work and for ensuring compliance with
all applicable Federal, State, county, and local regulations.
b. The Grantee shall provide the Agency with progress reports, both financial and programmatic,
semi-annually. Refer to the table below for the reporting period and due dates for progress and
budget reports.
Reporting Period Covered Date Reports are Due
October 1, 2016-March 31, 2017 April 10, 2017
April 1, 2017-September 30, 2017 October 10, 2017
October 1, 2017-March 31, 2018 April 10, 2018
April 1, 2018-September 30, 2018 October 10, 2018
In-kind and cash match shall be a part of the required financial reports, and documentation of the
reported match shall be included with the reports. Documents shall be in the form of individual time
sheets that have been signed by the individual employee and approved by the appropriate
supervisor, travel logs and invoices for in-kind match; copies of checks, bank deposits and fund
transfers for cash match. Other types of documents may be acceptable with the approval of the
Agency Manager.
c. The Grantee shall also submit a final grant report. Included in the final report, the Grantee shall
provide an accounting of final match claimed by the Grantee to fulfill the match requirement
mandated under N.C.G.S. 106-744(c1)(1). The Agency will retain 20% of the awarded grant
amount until the final report, including cash match and in-kind documentation, is received and
approved by the Agency.The final report and all invoices are due by the 1011'of the month following
the ending date of the contract and shall be paid within 60 days of the contract end date. If the final
report, all invoices, and supporting documentation have not been received by the 10th of the month
following the ending date of the contract the Grantee may not receive reimbursement and shall be
considered ineligible for reimbursement. Refer to the table below for final reporting dates:
NCDA&CS(Govt Development Project Contract Cover—State Appropriations Only)Rev. 11/15 Page 2 of 7
Reporting Forms Date Reports are Due
Letter requesting Extension and Updated June 30, 2018
Timeline
All progress reports, budget reports, August 10, 2018
reimbursement request, matching
documentation and other reporting documents
needed to close the contract
Final Reimbursement Payment November 30, 2018
d. Grantee monitoring shall be completed in accordance with the Agency"Agricultural Development
Project Monitoring Policy and Guidelines" and amendments thereto. The Grantee shall complete
and submit to the Agency the"Grantee Monitoring Checklist—Agricultural Development Project'to
report its annual monitoring findings. The first "Grantee Monitoring Checklist — Agricultural
Development Project' is due by December 31 of the following calendar year after the final report
(referred to Paragraph IV, Line C) has been submitted and approved, and annually thereafter for
five years.
e. The Grantee shall complete all reports in a prescribed format, which shall be provided by the
Agency. Reports and required documentation must be up-to-date in order for the Grantee to
receive payments.
f. All publicity and printed material regarding projects or activities supported in whole or in part by this
shall contain the following language: "The project received support from the NC ADFP Trust Fund."
The NC ADFP Trust Fund logo (digital versions of which can be downloaded from the NC ADFP
Trust Fund website at www.ncadfp.or4)shall be displayed in all the Grantee's publicity and printed
materials relating to this grant.
g. Non-compliance of grantee duties will result in an immediate suspension of existing Agency grant
funding, and the Grantee shall be ineligible for further Agency grants until the noncompliance is
corrected and the Agency has acknowledged the correction and the Grantee is in good standing.
V. Agency's Duties:
a. The Agency shall provide the grantee with their eligibility classification status based upon the
required reporting period as noted under "Grantee Duties" above. Grantee payments shall be
reflected by eligibility classification status subject to the Agency policy.
b. The Agency shall pay the Grantee in the manner and in the amounts specified in the Contract
Documents. The total amount paid by the Agency to the Grantee under this Contract shall not
exceed$32.500.
This amount consists of$N/A in federal funds.
This amount consists of$32,500.00 in State funds.
❑ a. There are no matching requirements from the Grantee.
❑b. There are no matching requirements from the Grantee; however, the Grantee has committed
the following match to this project:
❑ In Kind $
❑ Cash $
❑ Cash and In-kind $
❑ Cash and/or In-kind $
❑ I Other/Specify: $
® c. The Grantee's matching requirement is$32,500.00, which consists of:
❑ In Kind $
❑ Cash $
® Cash and In-kind $32,500.00
❑ Cash and/or In-kind $
❑ I Other/S eci $
t c U ?• ( 7
NCDA&CS(Govt Development Project Contract Cover—State propriations Only)Rev. 11/15 !� Page 3 of 7
❑ d. The Grantee has committed to an additional $n/a to complete the project as described in
Attachment B.
The contributions from the Grantee shall be sourced from non-federal funds.
The total Contract amount is$32.500.00.
c. The Agency shall initiate the monitoring protocols the following calendar year after the final report
(referred to Paragraph IV, Line C) has been submitted and approved unless directed prior to by the
Commissioner of Agriculture.
d. The Agency shall be responsible for the approval or denial of all required documentation and
reports submitted by the Grantee and notify Grantee of its findings.
VI. Conflict of Interest Policy:
The Agency has determined that the Grantee is a governmental agency and is not subject to N.C.G.S. § 143C-
6-23(b). Therefore, the Grantee is not required to file a Conflict of Interest Policy with the Agency prior to
disbursement of funds.
VII. Statement of No Overdue Tax Debts:
The Agency has determined that Grantee is a governmental agency and is not subject to N.C.G.S. § 143C-6-
23(c).Therefore,the Grantee is not required to file a Statement of No Overdue Tax Debts with the Agency prior
to disbursement of funds.
VIII. Reversion of Unexpended Funds:
Any unexpended grant funds shall revert to the Agency upon termination of this Contract.
IX. Reporting Requirements:
The Agency has determined that the Grantee is a governmental entity and is not subject to the State reporting
requirements mandated by N.C.G.S. § 143C-6-23. Therefore, the Grantee does not have to file annual
electronic reports with the NC Office of State Budget&Management.
X. Payment Provisions:
Upon execution of the contract, the Grantee may complete an"Initial Request for Payment"form for an amount
not to exceed $25,000. If the total grant amount is less than or equal to $31,250, no more than 80% of the
ADFP funds can be requested at this time. Invoices or other types of billing documents showing expenditure
use of these funds shall be submitted and approved by the Agency before additional payment request can be
submitted. The Grantee is limited to one payment request per month and shall be supported by appropriate
invoices, or other types of billing documents. The Grantee may request from the Agency all remaining funds
less 20%of the awarded grant amount(refer to Paragraph IV, Line C). At a later date, but prior to the expiration
date of the contract, the Grantee may request the final payment; which is the remaining 20% of the awarded
grant amount, upon the Grantee's submission of a final grant report determined to be in compliance with the
Agency's reporting specifications. The Agency may withhold reimbursements if the Grantee fails to accomplish
the milestones stated in Attachment B and D. All payments are subject to the availability of funds.
Payment shall be made in accordance with the Contract Documents and as described in the Scope of Work,
Attachment B.
Upon expiration of the contract date, the Grantee shall have until the 10th of the following month that the
contract ends, to get all documents and invoices to the agency in accordance with its approved budget in
Attachment C. Should the grantee have unspent funding remaining at the expiration date of the contract,
these unspent funds shall be immediately returned to the Agency. Under no circumstances shall the Grantee
encumber or expend funds provided under this contract after the contract expiration date.
NCDA&CS(Govt Development Project Contract Cover—State Appropriations Only)Rev. 11/15 Page 4 of 7
If this Contract is terminated prior to the original end date, the Grantee may submit a final "Request for
Reimbursement"form. All unexpended funds shall be returned by the Grantee to the Agency within 45 days of
the contract termination date. The Grantee shall also provide the Agency with a final report, in a format provided
by the Agency, within 45 days of the contract termination date. The final report will be used by the Agency to
determine the amount, if any, of expended funds to be returned to the Agency by the Grantee.
Eligible expenditures for payment must be within the fiscal period noted in the contract. Reimbursement may
not be considered prior to the submission and final execution of the Contract.
All matching funds, including in-kind and cash, must be spent concurrently with funds provided by this
Contract. Match may not be from a similar appropriation source such as the ADFP Trust Fund grant funding.
Both types of matching funds expended shall be accounted for on the Request for Reimbursement forms, and
support documentation for all matching expenditures shall be included with the forms.
All travel reimbursements shall be made in accordance with the current State rates, at the time of the
expenditure, and shall be made in accordance with the"State Budget Manual".
Due to fiscal year ending June 30, any reimbursement request received after June 15 is subject to payment in
the next fiscal year.
Indirect costs are not allowable expenditures under this Contract.
XI. Contract Administrators:
All notices permitted or required to be given by one Party to the other and all questions about the Contract from
one Party to the other shall be addressed and delivered to the other Party's Contract Administrator. The name,
post office address,street address,telephone number,fax number,and email address of the Parties'respective
initial Contract Administrator are set out below. Either Party may change the name, post office address, street
address,telephone number, fax number, or email address of its Contract Administrator by giving timely written
notice to the other Party.
For the Agency:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Veronica Jamsion, Adminstrative Officer I Veronica Jamison,Administrative Officer I
1001 Mail Service Center 1001 Mail Service Center
Raleigh, NC 27699 Raleigh, NC 27699
Telephone: 919-707-3071
Fax: 919-716-0105
Email: Veronica.Jamison@ncagr.gov
For the Grantee:
Grantee Contract Administrator-Mailing Address Grantee Principal Investigator or Key Personnel
Name: Ms. Bonnie Hammersly Title: County Name: Mike Ortosky Title: Agriculture Economic
Manager Developer
Company Name: Orange County Company Name: Orange County
Post Office Address: 200 South Cameron Street Street Address: 200 South Cameron Street
City: Hillsborough State: NC Zip: 27278 City: Hillsborough State: NC Zip: 27278
Telephone: 919-245-2337 Telephone: 919-245-2336
Fax: Fax:
Email: Bhammersl oran ecoun nc, ov I Email: MOrtosky@orangecountync.gov
NCDA&CS(Govt Development Project Contract Cover—State Appropriations Only)Rev.11/15 Page 5 of 7
X11. Supplementation of Expenditure of Public Funds:
The Grantee assures that funds received pursuant to this Contract shall be used only to supplement, not to
supplant, the total amount of federal, State and local public funds that the Grantee otherwise expends for
activities involved with specialty services and related programs. Funds received under this Contract shall be
used to provide additional public funding for such services. The funds shall not be used to reduce the Grantee's
total expenditure of other public funds for such services.
X111. Disbursements:
As a condition of this Contract, the Grantee acknowledges and agrees to make disbursements in accordance
with the following requirements:
a. Will implement or already has implemented adequate internal controls over disbursements
b. Pre-audit all invoices presented for payment to determine:
• Validity and accuracy of payment
• Payment due date
• Adequacy of documentation supporting payment
• Legality of disbursement
c. Assure adequate control of signature stamps/plates
d. Assure adequate control of negotiable instruments; and
e. Has procedures in place to insure that account balance is solvent and to reconcile the account monthly.
XIV. Outsourcing:
The Grantee certifies that it has identified to the Agency all jobs related to the Contract that have been
outsourced to other countries, if any. Grantee further agrees that it will not outsource any such jobs during the
term of this Contract without providing prior notice to the Agency. The Grantee will be responsible for the
performance of all its subgrantees and shall not be relieved of any duties and responsibilities of this contract.
XV. N.C.G.S.§133-32 and Executive Order 24:
N.C.G.S. § 133-32 and Executive Order 24 prohibit the offer to, or acceptance by, any State employee of any
gift from anyone with a Contract with the State, or from any person seeking to do business with the State. By
execution of any response in this procurement or Contract, you attest, for your entire organization and its
employees or agents,that you are not aware that any such gift has been offered, accepted, or promised by any
employee of your organization.
[This Contract is continued on the next page.]
NCDA&CS(Govt Development Project Contract Cover—State Appropriations Only)Rev. 11/15 Page 6 of 7
XVI. Signature Warranty:
The undersigned represent and warrant that they are authorized to bind their principals to the terms of this
Contract.
IN WITNESS WHEREOF, the Grantee and the Agency execute this Contract in two (2) originals, one (1) of
which is retained by the Grantee and one (1)which is retained by the Agency.
Grantee Orange County
Z�Z--3-": a ll 7 117
S nature of Authorized Representativ Dat
I��h Cfl A
Printed Name Title
Witness:
Signature Date
Printed Name Title
North Carolina Department of Agriculture and Consumer Services
Signature of Authorized Representa ive Date
N. David Smith, Chief Deputy Commissioner
Printed Name of Authorized Representative
NCDA&CS(Govt Development Project Contract cover—State Appropriations Only)Rev. 11/15 Page 7 of 7
Attachment A
General Terms and Conditions
PU¢I_iC.S CTOR CONTRACTS(Including local Governments)
General Terms and Conditions
DEFINITIONS amounts received as reimbursement for
Unless indicated otherwise from the context, the services rendered to individuals for Medicare
following terms shall have the following meanings in and Medicaid patient services.
this Contract. All definitions are from 9 NCAC (8) "Financial Statement" means a report
3M.0102 unless otherwise noted. If the rule or providing financial statistics relative to a
statute that is the source of the definition is changed given part of an organization's operations or
by the adopting authority, the change shall be status.
incorporated herein: (9) "Grant" means financial assistance provided
by an agency, grantee, or subgrantee to
(1) "Agency" (as used in the context of the carry out activities whereby the grantor
definitions below) shall mean and include anticipates no programmatic involvement
every public office, public officer or official with the grantee or subgrantee during the
(State or local, elected or appointed), performance of the grant.
institution, board, commission, bureau, (10) "Grantee" has the meaning in G.S. 143C-6-
council, department, authority or other unit of 23(a)(2): a non-State entity that receives a
government of the State or of any county, grant of State funds from a State agency,
unit, special district or other political department, or institution but does not
subagency of government. For other include any non-State entity subject to the
purposes in this Contract, "Agency" shall audit and other reporting requirements of the
mean the entity identified as one of the Local Government Commission. For other
parties hereto. purposes in this Contract, "Grantee" shall
(2) "Audit" means an examination of records or mean the entity identified as one of the
financial accounts to verify their accuracy. parties hereto.
(3) "Certification of Compliance" means a report (11) "Grantor" means an entity that provides
provided by the Agency to the Office of the resources, generally financial, to another
State Auditor that states that the Grantee has entity in order to achieve a specified goal or
met the reporting requirements established objective.
by this Subchapter and included a statement (12) "Non-State Entity" has the meaning in
of certification by the Agency and copies of N.C.G.S. 143C-1-1(d)(18): Any of the
the submitted grantee reporting package. following that is not a State agency: an
(4) "Compliance Supplement" refers to the North individual, a firm, a partnership, an
Carolina State Compliance Supplement, association, a county, a corporation, or any
maintained by the State and Local other organization acting as a unit. The term
Government Finance Agency within the includes a unit of local government and
North Carolina Department of State public authority.
Treasurer that has been developed in (13) "Public Authority" has the meaning in
cooperation with agencies to assist the local N.C.G.S. 143C-1-1(d)(22): A municipal
auditor in identifying program compliance corporation that is not a unit of local
requirements and audit procedures for
testing those requirements. government or a local governmental
authority, board, commission, council, or
(5) Contract" means a legal instrument that is agency that (i) is not a municipal corporation
used to reflect a relationship between the and (ii) operates on an area, regional, or
agency, grantee, and subgrantee. multiunit basis, and the budgeting and
(6) "Fiscal Year" means the annual operating accounting systems of which are not fully a
year of the non-State entity. part of the budgeting and accounting
(7) "Financial Assistance" means assistance that systems of a unit of local government.
non-State entities receive or administer in the (14) "Single Audit" means an audit that includes
form of grants, loans, loan guarantees, an examination of an organization's financial
property (including donated surplus statements, internal controls, and compliance
property), cooperative agreements, interest with the requirements of federal or State
subsidies, insurance, food commodities, awards.
direct appropriations, and other assistance. (15) "Special Appropriation" means a legislative
Financial assistance does not include act authorizing the expenditure of a
NCDA&CS-General Terms and Conditions—Public-Local Governmental Entities
Eff.07/14;4/15;1/17 Page 1 of
designated amount of public funds for a Subgrantees: The Grantee has the responsibility to
specific purpose. ensure that all subgrantees, if any, provide all
(16) "State Funds" means any funds information necessary to permit the Grantee to
appropriated by the North Carolina General comply with the standards set forth in this Contract.
Assembly or collected by the State of North
Carolina. State funds include federal Assignment: No assignment of the Grantee's
financial assistance received by the State obligations or the Grantee's right to receive payment
and transferred or disbursed to non-State hereunder shall be permitted. However, upon written
entities. Both federal and State funds request approved by the issuing purchasing authority,
maintain their identity as they are subgranted the State may:
to other organizations. Pursuant to N.C.G.S.
143C-6-23(a)(1), the terms "State grant (a) Forward the Grantee's payment check(s)
funds" and "State grants" do not include any directly to any person or entity designated by
payment made by the Medicaid program, the the Grantee, or
Teachers' and State Employees' (b) Include any person or entity designated by
Comprehensive Major Medical Plan, or other Grantee as a joint payee on the Grantee's
similar medical programs. payment check(s).
(17) "Subgrantee" has the meaning in G.S.
143C-6-23(a)(3): a non-State entity that In no event shall such approval and action obligate
receives a grant of State funds from a the State to anyone other than the Grantee and the
grantee or from another subgrantee but does Grantee shall remain responsible for fulfillment of all
not include any non-State entity subject to Contract obligations.
the audit and other reporting requirements of
the Local Government Commission. Beneficiaries: Except as herein specifically
(18) "Unit of Local Government has the meaning provided otherwise, this Contract shall inure to the
in G.S. 143C-1-1(d)(29): A municipal benefit of and be binding upon the parties hereto and
corporation that has the power to levy taxes, their respective successors. It is expressly
including a consolidated city-county as understood and agreed that the enforcement of the
defined by G.S. 160B-2(1), and all boards, terms and conditions of this Contract, and all rights of
agencies, commissions, authorities, and action relating to such enforcement, shall be strictly
institutions thereof that are not municipal
reserved to the Agency and the named Grantee.
Nothing contained in this document shall give or
corporations. allow any claim or right of action whatsoever by any
other third person. It is the express intention of the
Relationships of the Parties Agency and Grantee that any such person or entity,
Independent Contractor: The Grantee is and shall other than the Agency or the Grantee, receiving
services or benefits under this Contract shall be
be deemed to be an independent Contractor in the deemed an incidental beneficiary only.
performance of this Contract and as such shall be
wholly responsible for the work to be performed and Indemnity
for the supervision of its employees. The Grantee
represents that it has, or shall secure at its own Indemnification: The Grantee agrees to indemnify
expense, all personnel required in performing the and hold harmless the Agency, including any of its
services under this agreement. Such employees shall Divisions, and any of its officers, agents and
not be employees of, or have any individual employees, from liability of any kind, and from any
contractual relationship with, the Agency. claims of third parties arising out of any act or
omission of the Contractor in connection with the
Subcontracting: The Grantee shall not subcontract
any of the work contemplated under this Contract performance of this Contract to the extent permitted
by law.
without prior written approval from the Agency. Any
approved subcontract shall be subject to all Default and Termination
conditions of this Contract. Only the subcontractors
or subgrantees specified in the Contract documents Termination by Mutual Consent: The Parties may
are to be considered approved upon award of the terminate this Contract by mutual consent with 60
Contract. The Agency shall not be obligated to pay days notice to the other party, or as otherwise
for any work performed by any unapproved provided by law.
subcontractor or subgrantee. The Grantee shall be
responsible for the performance of all of its Termination for Cause: If, through any cause, the
subgrantees and shall not be relieved of any of the Grantee shall fail to fulfill its obligations under this
duties and responsibilities of this Contract. Contract in a timely and proper manner, the Agency
shall have the right to terminate this Contract by
NCDA&CS-General Terms and Conditions—Public-Local Governmental Entities
Eff. 07/14;4/15;1/17 Page 2 of
giving written notice to the Grantee and specifying Compliance with Applicable Laws
the effective date thereof.
Compliance with Laws: The Grantee shall comply
In that event, all finished or unfinished deliverable with all laws, ordinances, codes, rules, regulations,
items prepared by the Grantee under this Contract and licensing requirements that are applicable to the
shall, at the option of the Agency, become its conduct of its business, including those of federal,
property and the Grantee shall be entitled to receive State, and local agencies having jurisdiction and/or
just and equitable compensation for any satisfactory authority.
work completed on such materials, minus any
payment or compensation previously made. Equal Employment Opportunity: The Grantee
shall take affirmative action in complying with all
Notwithstanding the foregoing provision, the Grantee federal and State statutes and all applicable
shall not be relieved of liability to the Agency for requirements concerning fair employment of people
damages sustained by the Agency by virtue of the with disabilities, and concerning the treatment of all
Grantee's breach of this agreement, and the Agency employees without regard to discrimination by reason
may withhold any payment due the Grantee for the of race, color, religion, sex, national origin or
purpose of setoff until such time as the exact amount disability. For additional information see Title VI of the
of damages due the Agency from such breach can be Civil Rights Act of 1964 (42 U.S.C., 2000d, 2000e-
determined. The filing of a petition for bankruptcy by 16), Title XI of the Education amendments of 1972,
the Grantee shall be an act of default under this as amended (20 U.S.C. 1681-1683 and 1685-1686),
Contract. and section 504 of the Rehabilitation Act of 1973 as
amended (29 U.S.C. 794).
Waiver of Default: Waiver by the Agency of any
default or breach in compliance with the terms of this Executive Order 24: In accordance with Executive
Contract by the Grantee shall not be deemed a Order 24, issued by Governor Perdue, and N.C.G.S.§
waiver of any subsequent default or breach and shall 133-32, a vendor or contractor (i.e. architect, bidder,
not be construed to be modification of the terms of contractor, construction manager, design
this Contract unless stated to be such in writing, professional, engineer, landlord, offeror, seller,
signed by an authorized representative of the Agency subcontractor, supplier, vendor, or grantee), is
and the Grantee and attached to the Contract. prohibited from making gifts or giving favors to any
employee of the Agency of Agriculture and Consumer
Availability of Funds: The parties to this Contract Services. This prohibition covers those vendors,
agree and understand that the payment of the sums contractors, and/or grantees who:
specified in this Contract is dependent and contingent
upon and subject to the appropriation, allocation, and (a) have a Contract with a governmental
availability of funds for this purpose to the Agency. Agency; or
(b) have performed under such a Contract within
Force Majeure: Neither party shall be deemed to be the past year; or
in default of its obligations hereunder if and so long (c) anticipate bidding on such a Contract in the
as it is prevented from performing such obligations by future.
any act of war, hostile foreign action, nuclear
explosion, riot, strikes, civil insurrection, earthquake, For additional information regarding the specific
hurricane, tornado, or other catastrophic natural requirements and exemptions, vendors, contractors,
event or act of God. and/or grantees are encouraged to review Executive
Order 24 and N.C.G.S. § 133-32.
Survival of Promises: All promises, requirements,
terms, conditions, provisions, representations, Confidentiality
guarantees, and warranties contained herein shall
survive the Contract expiration or termination date Confidentiality: Any information, data, instruments,
unless specifically provided otherwise herein, or documents, studies or reports given to or prepared or
unless superseded by applicable federal or State assembled by the Grantee under this agreement
statutes of limitation. shall be kept as confidential and not divulged or
made available to any individual or organization
Intellectual Property Rights without the prior written approval of the Agency. The
Grantee acknowledges that in receiving, storing,
Copyrights and Ownership of Deliverables: All processing or otherwise dealing with any confidential
deliverable items produced pursuant to this Contract information it will safeguard and not further disclose
are the exclusive property of the Agency. The the information except as otherwise provided in this
Grantee shall not assert a claim of copyright or other Contract.
property interest in such deliverables.
NCDA&CS-General Terms and Conditions—Public-Local Governmental Entities
Eff.07/14;4/15;1/17 Page 3 of 4
Oversight Care of Property: The Grantee agrees that it shall
be responsible for the proper custody and care of any
Access to Persons and Records: The State Auditor property furnished to it for use in connection with the
and the using agency's internal auditors shall have performance of this Contract and will reimburse the
access to persons and records as a result of all Agency for loss of, or damage to, such property. At
Contracts or grants entered into by State agencies or the termination of this Contract, the Grantee shall
political subdivisions in accordance with General contact the Agency for instructions as to the
Statute 147-64.7 and Session Law 2010-194, Section disposition of such property and shall comply with
21 (i.e., the State Auditors and internal auditors may these instructions.
audit the records of the contractor during the term of
the Contract to verify accounts and data affecting Amendment: This Contract may not be amended
fees or performance). orally or by performance. Any amendment must be
made in written form and executed by duly authorized
Record Retention: Records shall not be destroyed, representatives of the Agency and the Grantee,
purged or disposed of without the express written
consent of the Agency. State basic records retention Severability: In the event that a court of competent
policy requires all grant records to be retained for a jurisdiction holds that a provision or requirement of
minimum of five years or until all audit exceptions this Contract violates any applicable law, each such
have been resolved, whichever is longer. If the provision or requirement shall continue to be
Contract is subject to federal policy and regulations, enforced to the extent it is not in violation of law or is
record retention may be longer than five years since not otherwise unenforceable and all other provisions
records must be retained for a period of three years and requirements of this Contract shall remain in full
following submission of the final Federal Financial force and effect.
Status Report, if applicable, or three years following
the submission of a revised final Federal Financial Travel Expenses: Reimbursement to the Grantee
Status Report. Also, if any litigation, claim, for travel mileage, meals, lodging and other travel
negotiation, audit, disallowance action, or other expenses incurred in the performance of this
action involving this Contract has been started before Contract shall be reasonable and supported by
expiration of the five-year retention period described documentation. State rates shall be used.
above, the records must be retained until completion International travel shall not be reimbursed under this
of the action and resolution of all issues which arise Contract.
from it, or until the end of the regular five-year period
described above, whichever is later. Sales/Use Tax Refunds: If eligible, the Grantee and
all subgrantees shall: (a) ask the North Carolina
Miscellaneous Department of Revenue for a refund of all sales and
use taxes paid by them in the performance of this
Choice of Law: The validity of this Contract and any Contract, pursuant to G.S. 105-164.14; and (b)
of its terms or provisions, as well as the rights and exclude all refundable sales and use taxes from all
duties of the parties to this Contract, are governed by reportable expenditures before the expenses are
the laws of North Carolina. The Grantee, by signing entered in their reimbursement reports.
this Contract, agrees and submits, solely for matters
concerning this Contract, to the exclusive jurisdiction Advertising: The Grantee shall not use the award of
of the courts of North Carolina and agrees, solely for this Contract as a part of any news release or
such purpose, that the exclusive venue for any legal commercial advertising.
proceedings shall be Wake County, North Carolina.
The place of this Contract and all transactions and Indirect Costs Policy: The Agency has adopted a
agreements relating to it, and their situs and forum, "Zero" policy that indirect costs are unallowable
shall be Wake County, North Carolina, where all expenditures in all State funded grant applications
matters whether sounding in Contract or tort, relating and/or grant guidance, informational or directional
to the validity, construction, interpretation, and documents.
enforcement shall be determined.
Allowable Uses of State Funds: Expenditures of
Headings: The Section and Paragraph headings in State funds by any grantee shall be in accordance
these General Terms and Conditions are not material with the Cost Principles outlined in the Office of
parts of the agreement and should not be used to Management and Budget (OMB) CFR Title 2, Part
construe the meaning thereof. 200 Uniform Administrative Requirements, as
applicable. If the grant funding includes federal
Time of the Essence: Time is of the essence in the sources, the grantee shall ensure adherence to the
performance of this Contract. cost principles established by the Federal Office of
Management and Budget. [09 NCAC 03M.0201
NCDA&CS-General Terms and Conditions—Public-Local Governmental Entities
Eff.07/14;4/15;1/17 Page 4 of 4
Attachment B
Scope of Work
Describe the target audience for this• The fund will benefit farmers across North Carolina. Any farmer
project: that sells product to PFAP businesses will benefit from increased
revenues. In particular, it will benefit farmers who sell produce
directly to businesses or through vendors of local food.Some
examples of the NC grownproducts currently purchased by PFAP
clients include: blueberries,strawberries, soybeans, pecans,
broccoli, spinach, basil, andtomatoes.lt will also benefit the food
processors in PFAP who purchase NC-grown food. The fund will
allow them to expand their capacity to purchase NC grown
food products.These beneficiaries include seasonal and year-
round processors of NC produce,food trucks, caterers,frozen-
popsicle makers, and tempeh companies.The Client Requested
Operations Purchase Fund funds will be used exclusively by PFAP
clients who source their food products exclusively from NC
farmers. In addition,-only PFAP clients who have a proven
payment record at PFAP will be eligible to receive assistance.
Eligible companies will complete an application process
established by PFAP.The client must complete a PFAP NC
Agriculture CROP Application. PFAP will oversea and adminstror
the loan program. Orange County will monitor and provide
oversite authority of the PFAP Loan Program.
Give an approximate number of In the first five years,the CROP will benefit an estimated 10
participants in the project that would businesses,which will in turn benefit a total of 50 farmers.The
benefit from the grant: estimated aggregate increase in revenue for NC farmers would
be$25,000/year. In addition,the fund will benefit a much higher
number of resale businesses that purchase client's product and
thus increase access and revenue for PFAP clients.
Describe the geographic area that the The CROP fund will directly benefit businesses in Orange,
project will cover: Chatham,Alamance, and Durham County, however,the benefits
radiate to all of North Carolina's counties. Directly in these four
counties,the CROP aids in providing a convenient location in
which farmers can market their agricultural products to the
clients of PFAP. In addition to the mentioned four counties,the
clients of PFAP source agricultural products from other counties
as well.
Describe similar projects, if any, in which This project is a new program for our organization. We hope to
your organization has been involved: pilot it for other food hubs in the state.
What community needs will the project As the state's farmland is lost to subdivisions, business offices
serve: and shopping centers, North Carolina also loses the rural culture
connected to the land. It is important to remember that no
matter where you live, North Carolina farmland is a part of your
life. It is the center of cuisine in our state,with its rich traditions
of home-style meals,famous barbeque and cookoffs. It is the
defining feature for the origin of many of our towns, including
one of the largest, Durham.Today,agriculture is in all of our
daily lives. It is included the clothes we wear,the food we eat,
and the fuel we put in our cars. To preserve agricultural land
is to preserve ourselves, and our way of life.Another component
that must be considered is the deep connection many share to
the natural beauty of farming communities, which make up a
major portion of our rural areas. We retreat to these locations to
escape our busy lives,while others use these areas to support
their families. This project not only helps to keep farms viable,
supporting the preservation of farmland and natural resources,
but also helps them to thrive and support the cultural resources
of North Carolina. Our clients advertise that they purchase from
NC farmers, deepening the public's connection to farmers and
raising awareness with consumers. As our clients continue to
source locally grown products,they are reconnecting the farmer
to the consumer. Finally, a supply chain for NC-grown food,
strengthened by food processors, improves North Carolinians'
access to local, nutritious produce.
Illustrate any permanent jobs to be The CROP fund allows PFAP clients to buy more food and grow
established by the project and estimate their businesses. Business growth will require clients to hire
their value to North Carolina agriculture/ additional food processing professionals, management
agribusiness sector: employees, and business services. Clients will also hire logistical
employees like truck drivers. Beyond clients, farms will hire
additional employees to harvest additional crops grown for
client business. In addition, PFAP clients may use co-processors
in North Carolina to add value to farm crops before it reaches
PFAP.These co-processors will hire additional employees to
process additional crops.These jobs will create a stronger local
food economy in North Carolina. In the long run, PFAP hopes our
local food manufactures will help influence larger manufacturers
to use local produce inputs. Mainstream adoption of locally
sourced products will create sustainable wealth for farmers for
years to come.
Attachment C
Budget and Budget Narrative
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Provide a brief description of the This grant will fund one half of$65,000 Client Requested
plan/project: Operations Purchase (CROP) Fund. Each ADFP grant dollar must
be matched with another funding source for the purpose of
purchsing NC grown products to be used be PFAP clients. The
fund will provide short-term cash flow assistance to our clients,
allowing them to defer payment on specialized services,
installation fees on new equipment,or consulting services during
their production season. Clients will then re-pay the fund as their
product is sold after production season. Only eligible businesses-
-are those that that purchase NC-grown produce .Through this
CROP Fund, PFAP and its clients will become stronger partners of
NC farms. The acquisition of NC Locally grown products assits in
diversifing potential farm marketing channels.The more
successful NC farms become,the more farmland is preserved as
farms grow and the farms become more profitable.
List specific outcomes to be achieved: • Increased purchasing of local produce by used by ADFP
Cleints
• Increase produce sales for 10 local farms
• Add 3 new PFAP clients that buy from local farms
• Increase the success rates and purchasing power of PFAP
Clients be 50%
•
•
•
Attachment D
Project Timeline
Project Timeline - Cycle IX
October 1, 2016- Request Application from PFAP Clients
December 31,
2016 $ _
Request/Accept PFAP Clients for 2017 Cycle.
January 1,2017- Request first payment from NCDA Fund. Begin
March 31, 2017 Covering Client Cash Flow Needs
$ 25,000.00 $ 10,000.00 $ 35,000.00
Cover Client Cash Flow Needs
April 1, 2017-
June 30, 2017
$ 7,500.00 $ 7,500.00
July 1,2017- Cover Client Cash Flow Needs
September 30,
2017 is 7,500.00 $ 7,500.00
October 1, 2017- Receive Client money to replenish Crop Fund
December 31, Review effectiveness of fund with Clients
2017
Request application from 2018 Participants.
$ _
Accept PFAP clients from 2017 cycle.Begin
January 1,2018- covering client cash flow needs
March 31, 2018
Cover Client cash flow needs
April 1, 2018-
June 30, 2018
July 1, 2018- Cover client cash flow needs Review
September 30, possibilites for expansion of fund.Review
2018 2017 client experience.
Attachment E
Owner/Maintenance Agreement(Equipment Purchases Only)
OWNER / MAINTENANCE AGREEMENT
1. Grantee shall retain ownership of the materials and equipment purchased
with grant funds for a minimum of five years. Grantee may request to sale
or dispose of grant funded equipment by written notification to the Agency
and with written Agency approval. The Agency shall have 30 days to
respond to the grantee. Any proceeds over$100.00 generated from the sale
or disposition of equipment purchased under this grant shall be returned to
the Agency within 30 days of sale.
2. All equipment purchases using grant funding shall be identified by the serial
number and picture identification by the Grantee and provided to the Agency
upon purchase and reimbursement request.
3. The Grantee shall keep all equipment in working order and maintained based
on manufacturer's recommendations.
4. For the first five years of ownership:
a. Grantee shall maintain and keep on file a record of all repairs for
inspection purposes. At a minimum this re_ cord shall include the
following information:
❑ Date of repair;
❑ Reason for repair;
❑ Cost of repair;
❑ List of replacement parts if any;
❑ Name of company and person who completed repair work; and
❑ If a warranty is associated with any replacement parts, it should
be placed on file.
b. Grantee shall keep manufacturer's warranties on file.
c. Grantee shall follow the "Agricultural Development Project Monitoring
Policy and Guidelines" and amendments there to.
5. Any changes to this agreement shall require written approval by the Agency.
No equipment will be purchased using grant funds.
Attachment F
NC Openbook Supplemental Information
NC OPENBOOK SUPPLEMENTAL INFORMATION
INSTRUCTIONS: Complete the information below and return it to the Contract Administrator identified in your
original contract.This information must be submitted as part of your contract. If you have questions, please contact
the Contract Administrator or the Alternate Contact as reflected in your contract.
PURPOSE:in January 2009,the Governor of North Carolina signed Executive Order 4.This Executive Order
requires certain information be collected from Grantees to enhance accountability and transparency of
State funds. Therefore,the information outlined below shall be submitted prior to the disbursement of any
State funds by the North Carolina Department of Agriculture and Consumer Services.
DUNS Number: Amendment Number
Grantee Name:Orange County TAX ID Number:
Fiscal Year Ends: December 31 Contract Number.
1. Brief Description and Background/History of your Organization.
Be sure to include the number of years in existence,number of employees,mission and goals of your organization.
We are a joint project of Alamance, Chatham, Durham, and Orange Counties, with Orange County. PFAP
is in the process of transitioning to a Non-Profit 501(c)(3).The PFAP's start began in 2007,with Weaver
Street Market and Whole Foods contributing to an area Feasibility Study of a food incubator for the
Piedmont.The PFAP construction started in 2010, and was completed in the Fall of 2011.We feature a
large variety of equipment to meet a variety food-business needs.
2. Current project timeline: Begin: October 1, 2016 End: September 30, 2018
3. Expected outcomes and specific deliverables.
(Example:Expected Outcome:Aquaculture operation will remain in business.Deliverable:Healthy food will be made
available for human consum lion.
Expected Outcome: PFAP Clients will have money to support operational cash flow expenses.
Deliverable: This will allow them to purchase thousands of dollars of additional local produce.
4. The Grantee's website URL:
5. *Primary County of Performance. County Name: Orange
(CONGRESSIONAL DISTRICT#MUST BE IDENTIFIED) Congressional District#: 6
6. "County of Benefit:
Single County: Yes ❑ No County Name: Orange
Statewide: El Yes I El No
Regional: LJ Yes I LJ No
7. If the answer to question number 6 is"Regional", list the counties receiving benefit.
*Primary County of Performance: County in which grantee is located.
**County of Benefit Identd ed county or counties in which funding will be spent and/or food commodities
will be received.
Attachment G
Performance Measures
PERFORMANCE MEASURES
Grantee Name: Orange County
Project Title: Orange County Food Fund
Tracking#:
Contract#:
NCGrants Award ID#:
ADFP Trust Fund Trackin #: ADM-ADFP-16-015
1. 1 Increased the success rates and purchasing power of PFAP clients by 50%/
2. Increased produce sales from local farms
3.
4.
5.
6.
7.
8.
9.
10.
1. As NC farmers and PFAP clients grow together,
they strengthen the long-term viability of local
supply chains that support the preservation of Farmland
2. PFAP partiipactes for the puchase of locally grown NC Products.
3.
4.
5.
6.
7.
8.
9.
10.
1. Provide listing of local producers that sale products to ADFP particaptes.
2. Listing of matching funding resources for each ADFP dollar used.
3. A management plan of how the ADFP Grant dollar would be continued matched
and loaned as a contineous program.
4. Provide an annual accounting report of PFAD Cleints using ADFP Funding with
amount of funding loaned and repayment of such funds..
5.
SAM.024—Performance Measures Page 1 of 1
Eff:7/10
Attachment H
Certifications and Assurances
Certifications and Assurances Section
CERTIFICATIONS REGARDING LOBBYING; DEBARMENT,SUSPENSION AND OTHER
RESPONSIBILITY MATTERS; AND DRUG-FREE WORKPLACE REQUIREMENTS
Applicants should refer to the regulations cited below to determine the certification to which they are
required to attest. Signature of this form provides for compliance with certification requirements under 34
CFR Part 82, "New Restrictions on Lobbying," and 34 CFR Part 85, "Government-wide Debarment and
Suspension (Nonprocurement) and Government-wide Requirements for Drug-Free Workplace (Grants)."
The certifications shall be treated as a material representation of fact upon which reliance will be placed
when the Department of Agriculture & Consumer Services determines to award the covered transaction,
grant, or cooperative agreement.
1.LOBBYING
As required by Section 1352, Title 31 of the U.S. Code, and implemented at 7 CFR Part 3018, for persons
entering into a grant or cooperative agreement over $100,000, as defined at 7 CFR Part 3018, Sections
3018.105 and 3018.110,the applicant certifies that
A. No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to
any person for influencing or attempting to influence an officer or employee of any agency, a Member
of Congress, an officer or employee of Congress, or an employee of a Member of Congress in
connection with the making of any federal grant, the entering into of any cooperative agreement, and
the extension, continuation, renewal, amendment, or modification of any federal grant or cooperative
agreement;
B. if any funds other than federal appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with this
federal grant or cooperative agreement, the undersigned shall complete and submit Standard Form -
LLL, "Disclosure Form to Report Lobbying,"in accordance with its instructions;
C. the undersigned shall require that the language of this certification be included in the award
documents for all subawards at all tiers (including subgrants, contracts under grants and cooperative
agreements, and subcontracts)and that all subrecipients shall'certify and disclose accordingly.
This certification is a material representation of fact upon which relevance was placed when this
transaction was made or entered into. Submission of this certification is a prerequisite for making or
entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the
required information or who makes a prohibited expenditure shall be subject to a civil penalty of not less
than$10,000 and not more than$100,000 for each such failure.
2.DEBARMENT,SUSPENSION,AND OTHER RESPONSIBILITY MATTERS
As required by Executive Order 12549, Debarment and Suspension, and implemented at 7 CFR Part
3017, for prospective participants in primary covered transactions, as defined at 7 CFR Part 3017.200,
Subpart B:
A. The applicant certifies that it and its principals:
a) Are not.presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from covered transactions by any federal department or agency;
b) have not within a three-year period preceding this application been convicted of or had a civil
judgment rendered against them for commission of fraud or a criminal offense in connection with
obtaining, attempting to obtain, or performing a public (federal, State, or local) transaction or
contract under a public transaction; violation of federal or State antitrust statutes or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of records, making false
statements, or receiving stolen property;
NCDA&CS Certifications&Assurances Page 1 of 3
Rev 7/14
c) are not presently indicted for or otherwise criminally or civilly charged by a governmental entity
(federal, State, or local)with commission of any of the offenses enumerated in paragraph 2. (A)(b)
of this certification.
d) Have not within a three-year period preceding this application had one or more public transaction
(federal, State, or local)terminated for cause or default.
B. Where the applicant is unable to certify to any of the statements in this certification, he or she shall
attach an explanation to this certification.
3.DRUG-FREE WORKPLACE(GRANTEES OTHER THAN INDIVIDUALS)
As required by the Drug-Free Workplace Act of 1988, and implemented at 7 CFR Part 3021, Subparts A,
B, and E,for grantees, as defined at 7 CFR Part 3021:
A The applicant certifies that it will or will continue to provide a drug-free workplace by:
a) Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the grantee's workplace and
specifying the actions that will be taken against employees for violation of such prohibition;
b) establishing an on-going drug-free awareness program to inform employees about:
i. The dangers of drug abuse in the workplace;
ii. The grantee's policy of maintaining a drug-free workplace;
iii. Any available drug counseling, rehabilitation, and employee assistance programs; and
iv. The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
c) making it a requirement that each employee to be engaged in the performance of the
grant be given a copy of the statement required by paragraph (a);
d) notifying the employee in the statement required by paragraph (a) that, as a condition of
employment under the grant, the employee will:
i. Abide by the terms of the statement; and
ii. Notify the employer in writing of his or her conviction for a violation of a criminal
drug statute occurring in the workplace no later than five calendar days after such
conviction;
e) notifying the agency, in writing, within 10 calendar days after receiving notice under
subparagraph (d)(ii) from an employee or otherwise receiving actual notice of such
conviction.
Notice shall include the identification number(s)of each affected grant;
f) taking one of the following actions, within 30 calendar days of receiving notice under
subparagraph(d)(ii),with respect to any employee who is so convicted:
i. Taking appropriate personnel action against such an employee, up to and
including termination, consistent with the requirements of the Rehabilitation Act of
1973 (29 U.S.C. 794), as amended; or
ii. requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a federal, State, or local
health, law enforcement, or other appropriate agency;
g) making a good faith effort to continue to maintain a drug-free workplace through
implementation of paragraphs(a), (b), (c), (d), (e), and (f).
NCDA&CS Certifications&Assurances Page 2 of 3
Rev 7/14
B. The grantee must provide the location site(s)for the performance of work done in connection with the
specific grant.
Place(s)of Performance(Street address, city,county, state,zip code)
DRUG-FREE WORKPLACE-(GRANTEES WHO ARE INDIVIDUALS)
As required by the Drug-Free Workplace Act of 1988, and implemented at 7 CFR Part 3021, Subparts
A, C, and E,for grantees, as defined at 7 CFR Part 3021:
A. As a condition of the grant, I certify that I will not engage in the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance in conducting any activity with the grant;
and
B. If convicted of a criminal drug offense resulting from a violation occurring during the conduct of any
grant activity, I will report the conviction, in writing, within 10 calendar days of the conviction, to the
agency.
Notice shall include the identification number(s)of each affected grant.
As the duly authorized representative of the Grantee, I hereby certify that the Grantee will
comply with the above certifications.
o16 �] 6
Grantee Orbkinization Na
Signature of Authorized RepresentoWe Date
Cow
2�4_M
Printed Name of Authorized Representative Title
NCDA&CS Certifications&Assurances Page 3 of 3
Rev.7114
Attachment I
Signature Card
Signature Card
r
CONTRACT& FINANCIAL DOCUMENTS
INSTRUCTIONS: Please read and fill in the required information to the right of each field where applicable. Provide the
requested printed and written signatures (in Blue Ink) of agency representatives in the designated areas. In the event
the affixed signature(s) are no longer valid, a revised form must be submitted prior to processing any contractual
documents or submitting"Request for Payments"or any other financial documents.
SECTION I.
Date: (a - -
Legal Applicant Organization/Agency Name:
Federal Tax Identification Number: -
II.
Certification:
By affixing my signature below, I certify that person(s) identified are designated having legal authorization to sign on
behalf of the organization named in Section I., above, for purposes of executing contractual documents and preparing,
approving and executing all financial documents; including"Requests for Payments." I understand the legal implications
of any and all misrepresentation, which include but are not limited to defrauding the State of North Carolina, and certify
that the person signing below has full authority to execute this Agreement on behalf of the named organization.
NON-GOVERNMENTAL ORGANIZATIONS ONLY
Board Chair, Executive Director, etc. Financial Representative, Treasurer, etc.
Print Name&Title: Print Name&Title:
Signature: Signature:
GOVERNMENTAL ENTITIES
Authorized Governmental Official Chief Fiscal Officer
Print e&Title: int Na e&Titl . �`
& Aul 'O
Signature: Signa r .
NCDA&CS-Signature Card—NGO&Governmental Page 1 of 1
Rev 7/14
Attachment J
W-9 Tax Information
Farm W-9 Request for Taxpayer Give Form to the
(Rev.December 2014) requester.Do not
Department of the Treasury Identification Number and Certification send to the IRS.
Internal Revenue Service
1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank.
Orange County
N 2 Business name/disregarded entity name,if different from above
N
a 3 Check appropriate box for federal tax classification;check only one of the following seven boxes: 4 Exemptions(codes apply only to
certain entitles,not Individuals;see
0 ❑IndivlduaVsole proprietor or ❑ C Corporation ❑ S Corporation ❑ Partnership ❑Trust/estate instructions on page 3):
o. c single-member LLC Exempt payee code(if any) C
16 ❑Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=partnership)0*
`p 3 Note.For a single-member LLC that is disregarded,do not check LLC;check the appropriate box In the line above for Exemption from FATCA reporting
y the tax classification of the single-member owner. code(If any)
Other(see instructions) Local Government (APpllas toacc.-f &t.1nd..Wde the U.S.)a v
R 5 Address(number,street,and apt,or suite no.) Requester's name and address(optional)
U
c. P.O. Box 8181
6 City,state,and ZIP code
N Hillsborough,North Carolina 27278
7 List account numbers)here(optional)
•. Taxpayer Identification Number(TIN)
Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid social security number m�
backup withholding.For individuals,this is generally your social security number(SSN).However,fora
resident alien,sole proprietor,or disregarded entity,see the Part I instructions on page 3.For other
entities,it is your employer identification number(EIN).If you do not have a number,see How to get a
TIN on page 3. or
Note.If the account is in more than one name,see the instructions for line 1 and the chart on page 4 for Employer identification number
guidelines on whose number to enter.
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and
2. 1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue
Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am
no longer subject to backup withholding;and
3. 1 am a U.S.citizen or other U.S,person(defined below);and
4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct.
Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage
interest paid,acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and
generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the
instructions on page 3.
Sign Signature of (
Here U.S.person► ! � ,,(,' Date 01 6
General Instructions •Form 1098(home mortgage interest),1098-E(student loan interest),1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted. •Form 1099-C(canceled debt)
Future developments.Information about developments affecting Form W-9(such •Form 1099-A(acquisition or abandonment of secured property)
as legislation enacted after we release It)is at www.irs.gov/fw9.
Use Form W-9 only If you are a U.S.person(including a resident alien),to
Purpose of Form provide your correct TIN.
An individual or entity(Form W-9 requester)who is required to file an information If you do not return Form W-9 to the requester with a TIN,you might be subject
return with the IRS must obtain your correct taxpayer identification number(TIN) to backup withholding.See What is backup withholding?on page 2.
which may be your social security number(SSN),individual taxpayer identification By signing the filled-out form,you:
number(ITIN),adoption taxpayer identification number(ATIN),or employer 1.Certify that the TIN you are giving is correct(or you are waiting for a number
identification number(EIN),to report on an information return the amount paid to to be issued),
you,or other amount reportable on an information return.Examples of information 2.Certify that you are not subject to backup withholding,or
returns include,but are not limited to,the following:
•Form 1099-INT(interest earned or paid) 3.Claim exemption from backup withholding If you area U.S.exempt payee,If
•Form 1099-DIV(dividends,including those from stocks or mutual funds) applicable,you are also certifying that as a U.S.person,your allocable share of
any partnership income from a U.S.trade or business is not subject to the
•Form 1099-MISC(various types of Income,prizes,awards,or gross proceeds) withholding tax on foreign partners'share of effectively connected Income,and
•Form 1099-B(stock or mutual fund sales and certain other transactions by 4.Certify that FATCA code(s)entered on this form(if any)indicating that you are
brokers) exempt from the FATCA reporting,is correct.See What is FATCA reporting?on
•Form 1099-S(proceeds from real estate transactions) page 2 for further information.
•Form 1099-K(merchant card and third party network transactions)
Cat.No.10231X Form W-9(Rev.12-2014)
Form W-9(Rev.1-2011)
Page 2
The person who gives Form W-9 to the partnership for purposes of Certain payees and payments are exempt from backup withholding.
establishing its U.S.status and avoiding withholding on its allocable See the instructions below and the separate Instructions for the
share of net income from the partnership conducting a trade or business Requester of Form W-9.
in the United States is in the following cases: Also see Special rules for partnerships on page 1.
• The U.S.owner of a disregarded entity and not the entity, Updating Your Information
• The U.S.grantor or other owner of a grantor trust and not the trust, You must provide updated information to any person to whom you
and claimed to be an exempt payee if you are no longer an exempt payee
•The U.S.trust(other than a grantor trust)and not the beneficiaries of and anticipate receiving reportable payments in the future from this
the trust. person.For example,you may need to provide updated information if
Foreign person.if you are a foreign person,do not use Form W-9. you are a C corporation that elects to be an S corporation,or if you no
Instead,use the appropriate Form W-8(see Publication 515, longer are tax exempt.In addition,you must furnish a new Form W-9 if
Withholding of Tax on Nonresident Aliens and Foreign Entities). the name or TIN changes for the account,for example,if the grantor of a
Nonresident alien who becomes a resident alien.Generally,only a grantor trust dies.
nonresident alien individual may use the terms of a tax treaty to reduce Penalties
or eliminate U.S.tax on certain types of income.However,most tax
treaties contain a provision known as a"saving clause."Exceptions Failure to furnish TIN.If you fail to furnish your correct TIN to a
specified in the saving clause may permit an exemption from tax to requester,you are subject to a penalty of$50 for each such failure
continue for certain types of income even after the payee has otherwise unless your failure is due to reasonable cause and not to willful neglect.
become a U.S.resident alien for tax purposes. Civil penalty for false information with respect to withholding.If you
If you are a U.S.resident alien who is relying on an exception make a false statement with no reasonable•basis that results in no
contained in the saving clause of a tax treaty to claim an exemption backup withholding,you are subject to a$500 penalty.
from U.S.tax on certain types of income,you must attach a statement Criminal penalty for falsifying information.Willfully falsifying
to Form W-9 that specifies the following five items: certifications or affirmations may subject you to criminal penalties
1.The treaty country.Generally,this must be the same treaty under including fines and/or imprisonment.
which you claimed exemption from tax as a nonresident alien. Misuse of TINs.If the requester discloses or uses TINS in violation of
2.The treaty article addressing the income. federal law,the requester may be subject to civil and criminal penalties.
3.The article number(or location)in the tax treaty that contains the
saving clause and its exceptions. Specific instructions
4.The type and amount of income that qualifies for the exemption Name
from tax.
5.Sufficient facts to justify the exemption from tax under the terms of If you are an individual,you must generally enter the name shown on
the treaty article. your income tax return.However,if you have changed your last name,
for instance,due to marriage without informing the Social Security
Example.Article 20 of the U.S.-China income tax treaty allows an Administration of the name change,enter your first name,the last name
exemption from tax for scholarship income received by a Chinese shown on your social security card,and your new last name.
student temporarily present in the United States.Under U.S.law,this If the account is in joint names,list first,and then circle,the name of
student will become a resident alien for tax purposes if his or her stay in
the United States exceeds 5 calendar years.However,paragraph 2 of the person or entity whose number you entered in Part I of the form.
the first Protocol to the U.S.-China treaty(dated April 30, 1984)allows Sole proprietor.Enter your individual name as shown on your income
the provisions of Article 20 to continue to apply even after the Chinese tax return on the"Name"line.You may enter your business,trade,or
student becomes a resident alien of the United States.A Chinese "doing business as(DBA)"name on the"Business nameldisregarded
student who qualifies for this exception(under paragraph 2 of the first entity name line.
protocol)and is relying on this exception to claim an exemption from tax Partnership,C Corporation,or S Corporation.Enter the entity's name
on his or her scholarship or fellowship income would attach to Form on the"Name"line and any business,trade,or"doing business as
W-9 a statement that includes the information described above to (DBA)name"on the"Business name/disregarded entity name"line.
support that exemption. Disregarded entity.Enter the owner's name on the"Name"line.The
If you are a nonresident alien or a foreign entity not subject to backup name of the entity entered on the"Name"line should never be a
withholding,give the requester the appropriate completed Form W-8. disregarded entity.The name on the"Name"line must be the name
What is backup withholding?Persons making certain payments to you shown on the income tax return on which the income will be reported.
must under certain conditions withhold and pay to the IRS a percentage For example,if a foreign LLC that is treated as a disregarded entity for
of such payments.This is called"backup withholding." Payments that U.S.federal tax purposes has a domestic owner,the domestic owner's
may be subject to backup withholding include interest,tax-exempt name is required to be provided on the"Name"line.if the direct owner
interest,dividends,broker and barter exchange transactions,rents, of the entity is also a disregarded entity,enter the first owner that is not
royalties,nonemployee pay,and certain payments from fishing boat disregarded for federal tax purposes.Enter the disregarded entity's
operators.Real estate transactions are not subject to backup name on the"Business name/disregarded entity name line.if the owner
withholding. of the disregarded entity is a foreign person,you must complete an
You will not be subject to backup withholding on payments you appropriate Form W-8.
receive if you give the requester your correct TIN,make the proper Note.Check the appropriate box for the federal tax classification of the
certifications,and report all your taxable interest and dividends on your person whose name is entered on the"Name"line(Individuallsole
tax return, proprietor,Partnership,C Corporation,S Corporation,Trust/estate).
Payments you receive will be subject to backup Limited Liability Company(LLC).If the person identified on the
withholding if. "Name"line is an LLC,check the"Limited liability company"box only
1.You do not furnish your TIN to the requester, and enter the appropriate code for the tax classification in the space
provided.If you are an LLC that is treated as a partnership for federal
2.You do not certify your TIN when required(see the Part 11 tax purposes,enter"P"for partnership.If you are an LLC that has filed a
instructions on page 3 for details), Form 8832 or a Fort 2553 to be taxed as a corporation,enter"C"for
3.The IRS tells the requester that you furnished an incorrect TIN, C corporation or"S"for S corporation.If you are an LLC that Is
4.The IRS tells you that you are subject to backup withholding disregarded as an entity separate from its owner under Regulation
section 301.7701-3(except for employment and excise tax),do not
because you did not report all your interest and dividends on your tax check the LLC box unless the owner of the LLC(required to be
return(for reportable interest and dividends only),or identified on the"Name"line)is another LLC that is not disregarded for
5.You do not certify to the requester that you are not subject to federal tax purposes.if the LLC is disregarded as an entity separate
backup withholding under 4 above(for reportable interest and dividend from its owner,enter the appropriate tax classification of the owner
accounts opened after 1983 only). identified on the"Name"line.
Form W-9(Rev.1-2011) Page 3
Other entities.Enter your business name as shown on required federal Part 1.Taxpayer Identification Number(TIN)
tax documents on the"Name"line.This name should match the name Enter your TIN In the appropriate box.if you are a resident alien and
shown on the charter or other legal document creating the entity.You you do not have and are not eligible to get an SSN,your TIN is your IRS
may enter any business,trade,or DBA name on the"Business name/ individual taxpayer identification number(ITIN).Enter it in the social
disregarded entity name"line. security number box.If you do not have an ITIN,see How to get a TIN
Exempt Payee below.
If you are exempt from backup withholding,enter your name as If you are a sole proprietor and you have an EIN,you may enter either
described above and check the appropriate box for your status,then your SSN or EIN.However,the IRS prefers that you use your SSN.
check the'Exempt payee"box in the line following the'Business name/ If you are a single-member LLC that is disregarded as an entity
disregarded entity name,"sign and date the form. separate from its owner(see Limited Liability Company(LLC)on page 2),
Generally,individuals(including sole proprietors)are not exempt from enter the owner's SSN(or EIN,if the owner has one).Do not enter the
backup withholding. Corporations are exempt from backup withholding disregarded entity's EIN.If the LLC is classified as a corporation or
for certain payments,such as interest and dividends. partnership,enter the entity's EIN.
Note.If you are exempt from backup withholding,you should still Note.See the chart on page 4 for further clarification of name and TIN
complete this form to avoid possible erroneous backup withholding. combinations.
The following payees are exempt from backup withholding: How to get a TIN.If you do not have a TIN,apply for one immediately.
To apply for an SSN,get Form SS-5,Application for a Social Security
1.An organization exempt from tax under section 501(a),any IRA,or a Card,from your local Social Security Administration office or get this
custodial account under section 403(b)(7)if the account satisfies the form online at www.ssa.gov.You may also get this form by calling
requirements of section 401(0(2), 1-800-772-1213.Use Form W-7,Application for IRS Individual Taxpayer
2,The United States or any of its agencies or instrumentalities, Identification Number,to apply for an ITIN,or Form SS-4,Application for
3.A state,the District of Columbia,a possession of the United States, Employer Identification Number,to apply for an EIN.You can apply for
or any of their political subdivisions or instrumentalities, an EIN online by accessing the IRS website at www.irs.gov/businesses
and clicking on Employer Identification Number(EIN)under Starting a
4.A foreign government or any of its political subdivisions,agencies, Business.You can get Forms W-7 and SS-4 from the IRS by visiting
or instrumentalities,or IRS.gov or by calling 1-800-TAX-FORM(1-800-829-3676).
5.An international organization or any of its agencies or if you are asked to complete Form W-9 but do not have a TIN,write
instrumentalities. "Applied For"in the space for the TIN,sign and date the form,and give
Other payees that may be exempt from backup withholding include: it to the requester.For interest and dividend payments,and certain
6.A corporation, payments made with respect to readily tradable instruments,generally
you will have 60 days to get a TIN and give it to the requester before you
7.A foreign central bank of issue, are subject to backup withholding on payments.The 60-day rule does
8.A dealer in securities or commodities required to register in the not apply to other types of payments.You will be subject to backup
United States,the District of Columbia,or a possession of the United withholding on all such payments until you provide your TIN to the
States, requester.
9.A futures commission merchant registered with the Commodity Note.Entering"Applied For"means that you have already applied for a
Futures Trading Commission, TIN or that you intend to apply for one soon.
10.A real estate investment trust, Caution:A disregarded domestic entity that has a foreign owner must
11.An entity registered at all times during the tax year under the use the appropriate Form W-8.
Investment Company Act of 1940, Part 11.Certification
12.A common trust fund operated by a bank under section 584(a), To establish to the withholding agent that you are a U.S.person,or
13.A financial institution, resident alien,sign Form W-9.You may be requested to sign by the
14.A middleman known in the investment community as a nominee or withholding agent even if item 1,below,and items 4 and 5 on page 4
custodian, or indicate otherwise.
15.A trust exempt from tax under section 664 or described in section For a joint account,only the person whose TIN is shown in Part 1
4947. should sign(when required). in the case of a disregarded entity,the
The following chart shows types of payments that may be exempt person identified on the"Name"line must sign.Exempt payees,see
from backup withholding.The chart applies to the exempt payees listed Exempt Payee on page 3.
above,1 through 15. Signature requirements.Complete the certification as indicated in
items 1 through 3,below,and items 4 and 5 on page 4.
IF the payment is for... THEN the payment is exempt 1.Interest,dividend,and barter exchange accounts opened
for... before 1984 and broker accounts considered active during 1983.
Interest and dividend payments All exempt payees except You must give your correct TIN,but you do not have to sign the
for 9 certification.
2.Interest,dividend,broker,and barter exchange accounts
Broker transactions Exempt payees 1 through 5 and 7 opened after 1983 and broker accounts considered inactive during
through 13.Also,C corporations. 1983.You must sign the certification or backup withholding will apply. If
Barter exchange transactions and Exempt payees 1 through 5 you are subject to backup withholding and you are merely providing
patronage dividends your correct TIN to the requester,you must cross out item 2 in the
certification before signing the form.
Payments over$600 required to be Generally,exempt payees 3.Real estate transactions.You must sign the certification.You may
reported and direct sales over 1 through 7 Y cross out item 2 of the certification.
$5,000'
'See Form 1099-MISC,Miscellaneous Income,and its instructions.
2 However,the following payments made to a corporation and reportable on Form
1099-MISC are not exempt from badcup withholding:medical and health care
payments,attorneys'fees,gross proceeds paid to an attorney,and payments for
services paid by a federal executive agency.
Steve Troxler North Carolina Department of Agriculture N.David Smith
Commissioner and Consumer Services Chief Deputy Commissioner
March 9, 2017
Ms. Bonnie Hammersly County Manager
Orange County
200 South Cameron Street
Hillsborough, NC 27278
ACCEPTANCE OF AWARD NOTIFICATION
Dear Ms. Hammersly:
On behalf of Commissioner Steve Troxler and the NC Department of Agriculture and Consumer Services, we
are pleased that you have accepted the Department's offer of$32,500.00.
By accepting our offer of financial assistance, you have agreed to the specific stipulations, terms and
conditions, and reporting requirements contained in the Contract that you signed. Enclosed is a fully
executed Contract for your records.
The forms listed below are used to fulfill the departmental reporting requirements of the North Carolina
Agricultural Development and Farmland Preservation Trust Fund. They may also be downloaded from our
website at www.ncadfp.org.
1. General Instructions
2. Initial Request for Payment/Request for Reimbursement
3. Progress Report
4. Budget Report
5. Equipment Inventory/In-Kind Summary
6. Initial Payment Documentation
If you have any questions regarding the Contract, please feel to contact Veronica Jamison at 919-707-3071
or by email at veronica.jamison @ncagr.gov.
erel ,
i
r
N. David Smith
Chief Deputy Commissioner
Enclosures
cc: Kathryn L. Caler, M.L.S., Grants&Contracts Administrator
Email: David.Smith@ncagr.gov
1001 Mail Service Center,Raleigh,North Carolina,27699-1001
(919)707-3033• Fax(919)715-0026
An Equal Opportunity Affirmative Action Employer
Form W-9(Rev.1-2011) Page 4
4.other payments.You must give your correct TIN,but you do not Note.if no name is circled when more than one name is listed,the
have to sign the certification unless you have been notified that you number will be considered to be that of the first name listed.
have previously given an incorrect TIN.'Other payments'include Secure Your Tax Records from Identity Theft
payments made in the course of the requester's trade or business for
rents,royalties,goods(other than bills for merchandise),medical and Identity theft occurs when someone uses your personal Information
health care services(including payments to corporations),payments to such as your name,social security number(SSN),or other identifying
a nonemployee for services,payments to certain fishing boat crew information,without your permission,to commit fraud or other crimes.
members and fishermen,and gross proceeds paid to attorneys An identity thief may use your SSN to get a job or may file a tax return
(including payments to corporations). using your SSN to receive a refund.
S.Mortgage interest paid by you,acquisition or abandonment of To reduce your risk:
secured property,cancellation of debt,qualified tuition program . Protect your SSN,
payments(under section 529),IRA,Coverdell ESA,Archer MSA or Ensure our employer is protecting your SSN,and
HSA contributions or distributions,and pension distributions.You Y p
must give your correct TIN,but you do not have to sign the certification. • Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a
What Name and Number To Give the Requester notice from the IRS,respond right away to the name and phone number
For this type of account: Give name and SSN of: printed on the IRS notice or letter.
If your tax records are not currently affected by identity theft but you
1.Individual The individual think you are at risk due to a lost or stolen purse or wallet,questionable
2.Two or more individuals Gant The actual owner of the account or, credit card activity or credit report,contact the IRS Identity Theft Hotline
account) If combined funds,the first at 1-800-908-4490 or submit Form 14039.
individual on the account
For more information,see Publication 4535,Identity Theft Prevention
3.Custodian account of a minor
The minor' and Victim Assistance.
(Uniform Gift to Minors Act)
4.a.The usual revocable savings The grantor-trustee' Victims of identity theft who are experiencing economic harm or a
trust(grantor is also trustee) system problem,or are seeking help in resolving tax problems that have
b.So-called trust account that is The actual owner' not been resolved through normal channels,may be eligible for
riot a legal or valid trust under Taxpayer Advocate Service(TAS)assistance.You can reach TAS by
state law calling the TAS toll-free case intake line at 1-877-777-4778 or TTYrrDD
5.Sole proprietorship or disregarded The owner' 1-800-829-4059.
entity owned by an individual Protect yourself from suspicious smalls or phishing schemes.
6.Grantor trust filing under Optional The grantor* Phishing is the creation and use of email and websites designed to
Forth 1099 Filing Method 1(see mimic legitimate business emails and websites.The most common act
Regulation section 1.6714(b)(2)(1)(A))
For this type of account: Give name and EIN of: is sending an email to a user falsely claiming to be an established
legitimate enterprise in an attempt to scam the user into surrendering
7.Disregarded entity not owned by an The owner private information that will be used for identity that
individual The IRS does not initiate contacts with taxpayers via emails.Also,the
8.A valid trust,estate,or pension trust Legal entity
The corporation IRS does not request personal detailed information through email or ask
9.Corporation or LLC electing
taxpayers for the PIN numbers,passwords,or similar secret access
corporate status on Fort 8832 or
Form 2553 information for their credit card,bank,or other financial accounts.
10.Association,dub,religious, The organization if you receive an unsolicited email claiming to be from the IRS,
charitable,educational,or other forward this message to phishing@irs.gov.You may also report misuse
tax-exempt organization of the IRS name,logo,or other IRS property to the Treasury Inspector
11.Partnership or multi-member LLC The partnership General for Tax Administration at 1-800-366-4484.You can forward
12.A broker or registered nominee The broker or nominee suspicious emails to the Federal Trade Commission at spam @uce.gov
13.Account with the Department of The public entity or contact them at www.ffc.govAdthefC or 1-877-I13THEFT
Agriculture in the name of a public (1-877-435-4338).
entity(such as a state or local Visit IRS.gov to learn more about identity theft and how to reduce
government,school district,or your risk.
prison)that receives agricultural
program payments
14.Grantor trust filing under the Form The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2($ee
Regulation section 1.6714(b)(2)01(B))
'List first and circle the name of the person whose number you furnish.9 only one person on a
joint account has an SSN,that person's number must be famished.
2 Circle the minor's name and furnish the minor's SSN.
3
You must show your individual nature and you may also enter your business or°DBA"name on
the'Business nameldiaregarded entity'name line.You may use either your SSN or EIN(if you
have one),but the IRS encourages you to use your SSN.
4 List first and circle the name of the trust,estate,or pension trust(Do not furnish the TIN of the
personal representative or trustee unless the legal amity itself is not designated inthe account
title.)Aso see Special rules ror parftmw rlpson page 1.
'Note.Grantor also must provide a Forth W-9 to trustee of trust
Privacy Act Notice
Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons(including federal agencies)who are required to file Information returns with
the IRS to report interest,dividends,or certain other income paid to you;mortgage interest you paid;the acquisition or abandonment of secured property;the cancellation
of debt;or contributions you made to an IRA,Archer MSA,or HSA.The person collecting this forth uses the information on the form to file information returns with the IRS,
reporting the above information.Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities,states,the District
of Columbia,and U.S.possessions for use in administering their laws.The information also may be disclosed to other countries under a treaty,to federal and state agencies
to enforce civil and criminal laws,or to federal law enforcement and intelligence agencies to combat terrorism.You must provide your TIN whether or not you are required to
file a tax return.Under section 3406,payers must generally withhold a percentage of taxable interest,dividend,and certain other payments to a payee who does not give a
TIN to the payer.Certain penalties may also apply for providing false or fraudulent information.
Attachment K
Vendor Electronic Payment Form
Office of the State Controller Vendor Electronic Payment Form
Return to:OSC Support Services Center �v� ""� '��� Email:osc.support.services(cr�osc.nc.gov-
Address: 1410 Mail Service Center s Telephone: 919-707-0795
Raleigh,NC 27699-1410
,, � °- -� E]New Add Request Fax: 919-981-5561
yy� c
ua��- _ ❑Change Existing ePay Account
For your convenience and benefit, the State of North Carolina offers payees the opportunity to receive future payments
electronically, rather than by check. Your payments will be deposited into the checking or savings account of your choice. In
addition to having the money deposited electronically,you also will be notified of the deposit either by fax or by e-mail. The fax or
e-mail will provide you with all the information that would normally be on your check stub. To receive payments electronically,you
must complete this form,attach a voided check,and return via mail,e-mail,or fax to the information listed above.
PRINT the following information. FAX or E-MAIL ADDRESS for payment notification.
(Place a check mark in front of the method that you prefer.)
Payee Name: Required E-mail Address:
Federal ID#/SSN#: If you would like to receive
remittances via fax, please
Payee Address for check the box below.
Otherwise remittances will
Applicable Accounts: be sent via E-mail.
❑ FAX Number:
Bank Name: Print Name and Title:
Bank Routing Number: Contact Phone Number:
❑ Checking Acct#: ❑ Savings Acct#:
ATTACH VOIDED CHECK OR PROVIDE A BANK LETTER WITH
ACH ROUTING/ACCOUNT INFO
I acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, as well as the
requirements of the Office of Foreign Assets Control(OFAC).Check one of the following:
❑ I affirm that, regarding electronic payments the State of North Carolina may remit to the financial institution for credit to the
account that I have designated,the entire payment amount is not subject to being transferred to a foreign bank account.
❑ I affirm that, regarding electronic payments the State of North Carolina may remit to the financial institution for credit to the
account that I have designated, the entire payment amount is subject to being transferred to a foreign bank account. I
understand that any electronic payments that may be remitted to me may be labeled with "AT"as the standard entry class. I
acknowledge that availability of funds credited to the account will be subject to my receiving financial institution's policies and
procedures. I also understand that the remitting agency may elect to remit future payments to me via paper check instead of
electronically.
I authorize the Office of the State Controller to initiate direct deposit entries each pay period, and if necessary, adjustments for any
direct deposit entries in error,to the financial institution and account identified on the attached certification document. I understand
and accept the conditions of participation in the direct deposit program.This authority will remain in effect until I cancel it in writing.
SIGNATURE: _7DATE:
CERTIFICATION OF ELIGIBILITY
Under the Iran Divestment Act
Pursuant to G.S. 147-86.59,any person identified as engaging in investment activities in Iran,
determined by appearing on the Final Divestment List created by the State Treasurer pursuant
to G.S. 147-86.58, is ineligible to contract with the State of North Carolina or any political
subdivision of the State. The Iran Divestment Act of 2015,G.S. 147-86.55 et seq.* requires that
each vendor, prior to contracting with the State certify, and the undersigned on behalf of the
Vendor does hereby certify,to the following:
1. that the vendor is not identified on the Final Divestment List of entities that the State
Treasurer has determined engages in investment activities in Iran;
2. that the vendor shall not utilize on any contract with the State agency any subcontractor
that is identified on the Final Divestment List; and
3. that the undersigned is authorized by the Vendor to make this Certification.
Vendor:
By:
Signature Date
Printed Name Title
The State Treasurer's Final Divestment List can be found on the State Treasurer's website at the address:
https://www.nctreasurer.com/inside-the-department/Or)enGovernment/Pages/Iran-Divestment-Act-Resources.aspx
and will be updated every 180 days. For questions about the Department of State Treasurer's Iran Divestment
Policy,please contact Meryl Murtagh at Meryl.Murtagh @nctreasurer.com or(919)814-3852.
* Note:Enacted by Session Law 2015-118 as G.S.143C-55 et seq.,but has been renumbered for codification at the
direction of the Revisor of Statutes.
ORANGE COUNTY
NORTH CAROLINA
ECONOMIC DEVELOPMENT
February 21,2017
Dewitt Hardee
North Carolina Department of Agriculture &Consumer Services
2 W. Edenton Street
Raleigh, NC 27601
Re: ADFP Trust Fund Grant—Orange County
Dear Mr. Hardee,
Enclosed please find three (3) copies of the signed contracts regarding the Orange County Crop Fund—
ADFP Grant. Once executed by your office, please return two (2) copies to the address below.
We appreciate the opportunity to work with your office to establish this fund to benefit North Carolina
Agriculture.
1
ike Ortosky
Agriculture Economic Developer
Orange County, North Carolina
131 W. Margaret Lane, Hillsborough, NC 27278 • (919) 245-2325 • www.orangecountync.gov
REQUEST TO ADFP TRUST FUND FOR APPROVAL OF SUBCONTRACTING
GRANTEE: OC ('4
Contract# : M °( -
Pursuant to the General Terms and Conditions of the Contract*between the Grantee and the
Age cy, Grant a here 4y reques s a roval of the attached contract between Grantee and (subcontractor)
�-r �r to assist in carrying out the purposes of the above
referenced contract.
`'� Date: /
Grantee Authorized Repres ative —7
Approved( Date: / s/
Dewitt Hardee
This grant and the subsequent revolving loan fund is intended to provide seasonal funding to clients of
the Piedmont Food and Agricultural Processing (PFAP) facility in Hillsborough, NC who purchase NC
Grown farm products for their value-added products.
The intent of this subcontracting request is to notify the Agency that matching funds as required by the
Grantee (noted in Section V, part C)will be provided to the Grantee (Orange County) by Weaver Street
Market Cooperative in Hillsborough, NC. These matching funds will not come from tax-funded accounts
in the County budget.
This agreement does not obligate Weaver Street Market(WSM) to agree to fund any loan which it(WSM)
determines to be unsuitable. Further, matching funds may be offered, in lieu of WSM matching, by the
loan applicant.
* Subcontracting: The Grantee shall not subcontract any of the work contemplated under this Contract
without prior written approval from the Agency. Any approved subcontract shall be subject to all
conditions of this Contract. Only the subcontractors or subgrantees specified in the contract documents
are to be considered approved upon award of the contract. The Agency shall not be obligated to pay for
any work performed by any unapproved subcontractor or subgrantee. The Grantee shall be responsible
for the performance of all of its subgrantees and shall not be relieved of any of the duties and
responsibilities of this Contract.