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HomeMy WebLinkAbout2018-031-E Finance - OC Disability Awareness Council outside performance agreementDocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2017, ( "Effective Date ") by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ( "County ") and OC Disability Awareness Council, a not - for - profit corporation, located at 503 W. Franklin Street Room 113, Chapel Hill, NC 27516 ( "Provider "). LVAT" ►11Y.y2M WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and OC Disability Awareness Council agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30, 2018. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of $8,250. b. All funds appropriated shall be used for purposes described in Exhibit B. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $2062.50. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Revised 712017 Page I of 7 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 — December 31; January 1 — March 31 and April 1 - June 30. Reports are due on January 12, April 13, and July 13 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services, upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as "default "), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten (10) business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7117 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non -owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury, bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: Il�f.` 1i17_\ �[ ���7�f. Y�1: 7it7111[ �l► i�ihil ul�l� ■:75L�I�Iii�1�7K�1` /�17_�ff�! • Worker's Compensation • Commercial General Liability • Automobile Liability • Professional Liability Limits for Coverage A - Statutory State NC & Coverage B - Employers Liability $500,000 each accident, disease policy limit and disease each employee $1,000,000 Each Occurrence $2,000,000 Aggregate $500,000 Combined Single Limit $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability) required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough, NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7117 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 12. Non - Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. 13. Non - Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non - discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 13.75 per hour. To the extent possible, Orange County recommends that OC Disability Awareness Council provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7117 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 County: Finance & Administrative Services Orange County Post Office Box 8181 Hillsborough, NC 27278 Provider: OC Disability Awareness Council 503 W. Franklin Street Room 113 Chapel Hill, NC 27516 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. 18. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti - discrimination laws, policies, rules, and regulations and the Orange County Non - Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http: / /www.orangecountync.gov/ departments / purchasing _division /contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147- 86.58. 19. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. F oocusigned by: f the Provider 'iw, Nb s 8F530EBA237945B... Timothy Miles, Executive Director (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Rev. 7117 1/24/2018 Date Page 5 of 10 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 For ar [ DocuSi9nedby, unty Government �6ln�(' h++►tiwttk" 0637994B755E477... Bonnie Hammersley, County Manager (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Rev. 7117 2/5/2018 Date Page 6 of 10 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION FY 2017 -2018 Outside Agency Funding Application HUMAN SERVICES • ORANGE COUNTY • TOWN OF CARRBORO • TOWN OF CHAPEL HILL Orange County (OC) Town of Carrboro (CA) Town of Chapel Hill (CH) 200 S. Cameron Street 301 W. Main Street 405 Martin Luther King, Jr. Blvd. Hillsborough, NC 27278 Carrboro, NC 27510 Chapel Hill, NC 27514 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION INFORMATION Each year, Orange County Government, the Town of Carrboro and the Town of Chapel Hill invite program funding requests from non - profit providers that support the delivery of vital community services. The application process is very competitive and not all applicants will be awarded funding. Recommendations for funding may be for an award amount less than that requested by the applicant. Agencies that are currently receiving funds from Orange County, the Town of Carrboro, or the Town of Chapel Hill local governments, and are also applying for new funds, must be in compliance with all terms of their current agreement(s) and must not have any outstanding audit findings, monitoring findings or concerns as determined by the municipality. Recipients are required to submit written progress reports on their SMART Measures that include: goals, description of activities /challenges, revisions of timelines /budgets, and other relevant information Funded projects will be monitored for progress and performance, financial and administrative management, and compliance with the terms of Performance /Development Agreement(s). Monitoring may involve site and /or office visit(s). Once applications are received, they are reviewed by staff for completeness and eligibility. The applications are presented to a specific application review group, depending on the funding source. The review group will make a recommendation, based on available funding and the priorities identified by the participating jurisdiction. The recommendation is presented to the appropriate Board /Council for consideration and approval. The Board /Council approves /adopts the final allocations. TIMELINE November 15 Funding Application Posted on Websites November 29 Funding Application Workshop Held October 18- January 23 Agency Prepares Application January 10 January 31 Q &A Session Held Application Submissions are Due March - May Application Review & Agency Presentations June Agency Funding Approval by Board /Council July Contracts Executed & Programs Begin DO NOT SUBMIT THIS PAGE 2/9/2017 4:31:06 PM Page 2 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION SUBMITTAL INFORMATION Welcome to the Outside Agency Common Funding application for local /general funds, which will be distributed through this competitive application process. All entities or organizations requesting funds must complete and submit this application prior to the deadline to be considered for FY 2017 -2018 funding. The Application Submittal Deadline is: Tuesday, January 31, 2017 5:00 PM In the event of inclement weather, check the website for each Town /County you are applying to, for further instructions. Please note that late, handwritten, or incomplete applications will not be accepted. (Applications not signed by the Chair or President of the Board of Directors, are considered incomplete.) An application orientation workshop will tentatively be held on Tuesday, November 29, 2016 at 9 AM to Noon to review the application and submittal requirements. SUBMITTAL REQUIREMENTS FOR EACH MUNICIPALITY Human Services— Town Of Carrboro Applications are accepted once a year and reviewed by the Town's Human Services Advisory Commission, which makes a recommendation for funding to the Board of Aldermen for final approval. For more information about the Town of Carrboro Human Services program, see here. Questions and submittals should be directed to: Annette Stone, 301 W. Main Street Carrboro, NC 27510 919- 918 -7319 astone cj�townofcarrboro.org Submission: We strongly encourage applications to be single- spaced, with 12 -point arial font and normal margins. Application: One (1) original plus Two (2) paper copies of the application must be hand delivered or mailed to Annette Stone, 301 West Main Street, Carrboro, NC 27510; AND One Application and Attachments files must be submitted by email. Any .pdf files must be accompanied by the original file format of .doc, .xIs, etc. DO NOT SUBMIT THIS PAGE 2/9/2017 4:31:06 PM Page 3 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Human Services — Town Of Chapel Hill In 1982, the Town established local funding to support local nonprofit organizations that carry out human service work throughout the community. Applications are accepted once a year and reviewed by the Town's Human Services Advisory Board, which makes a recommendation for funding to the Town Council for final approval. For more information about the Town of Chapel Hill Human Services program, see here. Questions and submittals should be directed to: Jackie Thompson 405 Martin Luther King Jr. Blvd. Chapel Hill, NC 27514 919- 969 -5081 jhompson(c�townofchapelhill.org Submission: ➢ We strongly encourage applications to be single- spaced, with 12 -point arial font and normal margins. Application: Two (2) paper copies of the application with ORIGINAL signatures must be hand delivered or mailed to Jackie Thompson, 405 Martin Luther King, Jr. Blvd., Chapel Hill, NC 27514; AND Attachments: The application submittal must be accompanied by a flash drive with the application and all attachment files in electronic format. Any .pdf files must be accompanied by the original file format of .doc, .xls, etc. Human Services— Orange County For more information about the Orange County Human Services program, see here. Questions and submittals should be directed to: Allen Coleman PO Box 8181 Hillsborough, NC 27278 (919) 245 -2151 acoleman(o)_orangecountync.gov Submission: Email application and ALL Attachments prior to the deadline. Any .pdf files must be accompanied by the original file format of .doc, .xIs, etc. Please request a delivery receipt of email with application and attachments. DO NOT SUBMIT THIS PAGE 2/9/2017 4:31:06 PM Page 4 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 Agency Program(s) EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Received By Date /Time / Section Subsection 1. Cover Page a. ❑ Applicant Contact Information b. ❑ Funding Requests C. ❑ Signed Application Cover Page d. ❑Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. ❑ Agency's Years in operation b. ❑ Agency's Purpose /Mission c. ❑ Agency's Types of Services Provided d. ❑ Agency's Experience with Programs e. ❑ Other Pertinent Agency Information f. ❑ Schedule of Positions g. ❑ Living Wage h. ❑ Agency Budget 3. Program Information a. ❑ Human Services Needs Priority b. ❑ Type of Program A separate Section 3 is c. ❑ Agency Collaboration required for each program. d. ❑ Summary of Program e. ❑ Description of Identified Need f. ❑ Description of Population to be Served g. ❑ Program Staffing, Capacity, & Expertise h. ❑ Program Implementation Timeline L ❑ Value of Investment j. ❑ Impact of Reduced /No Allocation k. ❑ Other Pertinent Information I. ❑ Target Population /Beneficiary Chart M. ❑ Work Statement n. ❑ Program Budget, Detail, & Cost per Individual 4. Attachments a. ❑ Audit: Organizations receiving $300,000 or more in Federal financial assistance, and /or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. ❑ IRS Federal Form 990 c. ❑ NC Solicitation License d. ❑ IRS Federal Tax - Exemption Letter e. ❑ Certificate of Insurance f. ❑ List of Board of Directors g. ❑ Solid Waste Program Fee (SWPF) Verification Application Submittal Checklist 2/9/2017 4:31:06 PM Page 5 of 22 DocuSign Envelope ID: 07FEE1A8-- �E83�rF-- 44CF- 9l9IC4 -6l A6EEg4aC`399BD2 ",ppuoa ,tArog faHonp�CIVIUffg51 nLalg.QiWt illty_Awareness Council ION Applicant Organization's Physical Address: 504 West Franklin Street Chapel Hill, NC 27514 Applicant Organization's Mailing Address: 504 West Franklin Street Chapel Hill, NC 27514 Applicant Organization's Web Address: www.trianciledac.org Executive Director: Dr. Timothy Miles Telephone Number: 919 -245 -4337 E -Mail: ocdac(q�,ararlgecpgntync.goy Tax ID 'Number: 58- 2062891 b) Funding Request List all FY17 -18 Human Services HS Funding Being Requested — For All Programs) and the Proposed Use of Funds (2 -3 lines or less) Program Carrboro Ch_ apel Hill - HS Orange Count - HS _ - Total -- -HS Ex. Youth Afterschool- Program Afterschool Program Coordinator salary and materials for youth actlVities and omiects $10,000 $15,000! $5,.000 $30,000 Technology Training and Equipment [disabled 3000 3500 3500 $10,000 Para -time Staff Grant Writer /Admin 3500 3500 3000 $10,000 Professional Training and ADA Related Servs 3500 3500 3000 $10,000 I Totals $30,000 c) To the best of my knowledge and belief all information and data in this application is true and current. The doe ent has been duly authorized by the governing board of the applicant, 7/1 n Signature: xe 6ve(birebto l,� Date Signature: `"' Boa airrs Date AGENCY INFORMATION 211/2017 9'47:16 AM a g e 6 of 2 2 .. DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4 -6l A6E4C39BD2 ' Wr 2J 1� l..y VYi 1141 f VV111 "J 1.0211 y11 Km. VLAt a n.4 FA U91 ell! l Ul members af��r�at�Tr�irI�eiiirasY APPLICATION ff YES NO ❑ x❑ a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ x❑ b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? U x❑ c) Current beneficiaries of the program for which funds are being requested? ❑ x[] d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity /expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti- discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. F . ---1 0 % , . ( j - - Signature: xecutive Dire ` � R A4 _RaSignature: _ Bo 4 hairper on l -.-7 Date Date AGENCY INFORMATION 2/112017 9:01:31 AM P a g e 8 o f 2 3 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 6lA6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): 02/1999 b) Agency's Purpose /Mission (no more than a few sentences): The mission of the Disability Awareness Council is to identify barriers to people with disabilities and create change. Our mission is to raise awareness levels regarding all aspects of disability — whether permanent or temporary conditions. c) Types of Services the Agency Provides (bullet format): • Working with the Career Development Center to find jobs • Computer workshops • Assessment Assistance for program and facility accessibility • Counseling to assist students in developing effective learning strategies and self - advocacy skills • Disaster Preparedness Training d) Agency's History with Providing These Services: TDAC has been providing disability accommodating resources since its inception in 1970. All of our council member administrators hold advanced training /degrees in some sort of vocational counseling. We each also bring a wealth of lived experience to the table. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director? Are there new initiatives ?) NO f) Schedule of Positions 14 Part -time staff and 5 Part -time volunteers etc. Full Time Equivalent (FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE - Full -Time Paid Positions: 0 # of FTE - Paid Part -Time Positions: 0 # of Volunteers: 5 # of FTE - Volunteers:5 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes /No) No Agency Information 2/9/2017 4:31:06 PM Page 8 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION If yes, is this agency an Orange County Living Wage Certified Employer? If no, please explain. TDAC is solely based on contract employees. h) Agency Budget Is your agency currently receiving and /or requesting other (non -Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes /No) Yes If yes, please list below: Include all programs that have funding requests /awards /totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY16 -17 Award FY17 -18 Request Source Ex: Affordable Rental Rehabilitation 0 $20,000 Carrboro - Affordable Housing Ex: Agency Administration $15,000 $15,000 Carrboro — Other Ex. Total $15,000 $35,000 Carrboro Total Funding Orange County Government $7,000 $15,000 Town of Chapel Hill $7,000 $15,000 Town of Carrboro $5,500 $20,000 Total $19,500 $50,000 *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues • Private Donations • Program Generated Revenue Agency Information 2/9/2017 4:31:06 PM Page 9 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 6lA6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION • Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG /HOME /etc.) • Private Foundation Grants • Other Revenue • Expenditures • Compensation • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses iii. Does your agency budget show a Surplus or Deficit? Yes Is there a significant change? Yes /No No, unchanging surplus of $2,000 Please provide a brief explanation for Surplus or Deficit, and significant changes. iv. What is your agency's fiscal year? July 1, 2016 through June 30, 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 2/9/2017 4:31:06 PM Page 10 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Adaptive Technology Training/ Career Development Program Primary Contact and Title: Dr. Tim Telephone Number: 919 - 245 -4337 Miles. Executive Director E -Mail: timothy.miles(a_triangledac.org a) Indicate the type of Human Service Needs Priority, if program applicable: X❑ Priority Area #1: safety -net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods /Residents Affordable Housing X X X Affordable Healthcare Education X X X X Family Resources Jobs /Jobs Training X X X X Food Transportation X X X Other: Special Technology X X X Training c) Provide a bulleted list of other agencies, if any, with which your agency coordinates /collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated /collaborative efforts. • The Orange County Disability Awareness Council training programs are being developed and implemented with the collaboration of: • Team ing4Technologies, the United Way • NC ADA Network • UNC Apples Interns, High School Service - Learning, UNC PA Interns • Various Orange County offices: OC Libraries, Adult Social Services, etc. • NC Central Food Bank • OC Senior Centers o S.H.I.P. • Triangle Transit, and area transit agencies • Various Chapel Hill, Carrboro offices • Volunteer Center of Durham • We invite any other social agencies that desire training or consulting concerning implementation of the ADA and customer service to people with disabilities. PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 11 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 6lA6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION We publish a bi- annual newsletter and post all events in print and electronic media to the OCDAC website. www.triangledac.org is a major social media source, linking us to organizations such as the NC Housing Coalition and New House Project, OPC Mental Health, NC Central Food Bank, and Triangle Transit. We have undertaken collaborative projects in housing for persons with disabilities with Housing and Human Rights and the Center for Economic Justice in Raleigh. We have an ongoing collaborative relationship with UNC Apples, A Helping Hand, and Chapel Hill High School — Service Learning and the NC Works Center. We have and plan to expand the use of volunteer UNC - Chapel Hill students and hopefully students from other area colleges. We are also continuing to work on developing a cooperative program with North Carolina Services for the Blind. TDAC is a workforce development partner, which is designed to align with employers and employees with disabilities in their career goals and job matches. Furthermore, the purpose of TDAC overall programs is to provide each citizen with the skills and necessary trainings to support their employment efforts and job placements. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town /County priority /goal? - Program participants (excluding vendors) will learn about specific assistive technologies that can facilitate education and employment opportunities. The computer and assistive technology classes educate citizens about technology which can be used in the home and on the job. All of the Triangle Disability Awareness Council ( OCDAC) provides job counseling and training, which will require collaboration with OC NC Works partner agencies in client's job readiness development, e.g. voice over Ipad, speech input /output. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro goals, or other community priorities (i.e. Council /Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. - The program promotes the concept of fostering self- sufficiency among persons with disabilities, and fulfills the County and Tri -city government priorities... e.g. affordable /accessible housing, unemployment, accessible and safe living. The Triangle Disability Awareness Council (TDAC) expects to further develop its existing programs, and that will enable more clients to get food delivered the same day, technology training to find gainful employment, city /county ADA related facility assessments, etc. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? - Disabled youth of legal working age, adults, and older adults are our target population. PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 12 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 6lA6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) - Our current volunteer technology instructor is a retired computer science instructor. Our executive director is an experienced vocational rehabilitation counselor. We also collaborate with supportive professionals. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. - Classes will be offered 5 days per week and 2 Saturdays per month beginning July first until June 30. i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) - Funding Adaptive Technology Training will add to each of the local government's employee pool and reduce the number of unemployed disabled people. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. - If Adaptive Technology Training is not funded, TDAC cannot expand the technology services it provides, cannot pay a technology instructor, and would not have a grant writer after our intern grant writer completes her assignment on March 7. k) Include any other pertinent information. PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 13 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: ADA Technical Assistance Training /Housing, Employment, and Transportation Program Primary Contact and Title: Dr. Tim Telephone Number: 919 - 245 -4337 Miles. Executive Director E -Mail: timothy.miles(a_triangledac.org /) Indicate the type of Human Service Needs Priority, if program applicable: X❑ Priority Area #1: safety -net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents m) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods /Residents Affordable Housing X X X Affordable Healthcare Education X X X X Family Resources Jobs /Jobs Training X X X X Food Transportation X X X Other: Special Technology X X X Training n) Provide a bulleted list of other agencies, if any, with which your agency coordinates /collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated /collaborative efforts. • The Orange County Disability Awareness Council training programs are being developed and implemented with the collaboration of: • Team ing4Technologies, the United Way • NC ADA Network • UNC Apples Interns, High School Service - Learning, UNC PA Interns • Various Orange County offices: OC Libraries, Adult Social Services, etc. • NC Central Food Bank • OC Senior Centers o S.H.I.P. • Triangle Transit, and area transit agencies • Various Chapel Hill, Carrboro offices • Volunteer Center of Durham • We invite any other social agencies that desire training or consulting concerning implementation of the ADA and customer service to people with disabilities. PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 14 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION We publish a bi- annual newsletter and post all events in print and electronic media to the OCDAC website. www.triangledac.org is a major social media source, linking us to organizations such as the NC Housing Coalition and New House Project, OPC Mental Health, NC Central Food Bank, and Triangle Transit. We have undertaken collaborative projects in housing for persons with disabilities with Housing and Human Rights and the Center for Economic Justice in Raleigh. We have an ongoing collaborative relationship with UNC Apples, A Helping Hand, and Chapel Hill High School — Service Learning and the NC Works Center. We have and plan to expand the use of volunteer UNC - Chapel Hill students and hopefully students from other area colleges. We are also continuing to work on developing a cooperative program with North Carolina Services for the Blind. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: o) Summarize the program services proposed and how the program will address a Town /County priority /goal? - The Americans with Disabilities Act was enacted to ensure that people with disabilities have equal access to goods and services. Training workshops focus on challenges that persons with disabilities face in pedestrian safety and community travel transition preparedness. This program offers business, i.e. employer, services providers etc. educational training in the areas that effect the nature of how they make reasonable accommodations. p) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro goals, or other community priorities (i.e. Council /Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. - This program serves to make the community a more accessible and safe place for every citizen. The workshops focus on preventative measures as well as everyday practices that can be employed by not only individuals with disabilities, but other residents and business owners as well. q) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? - Disabled youth of legal working age, adults, and older adults are our target population. r) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) - Our executive director is an experienced vocational rehabilitation counselor. We also collaborate with supportive professionals. Occasionally, the TDAC will hire specialists in key areas. s) Describe the specific period over which the activities will be carried out and include an implementation timeline. PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 15 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 6lA6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION - Periodic workshops throughout the year that can act as an ongoing planning and training process for all. t) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) - It helps persons with disabilities, families, advocates, and agencies identify resources in a consolidated manner. Since programs change over a period of time, the TDAC remains stationary for all of its citizens as a guide to foster self- sufficiency and independence. u) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. - Specialized services to the disabled would diminish, and efforts by social services and agencies alike would double in providing badly- needed services. v) Include any other pertinent information. PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 16 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information a) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Gender Male Female *City /State /County Disabled Total Ethnicity African - American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Total Of the above, how many Hispanic /Latino Of the above, how many non - Hispanic /Latino Total Age Geographic Location 0 -5 years 6 -18 years 19 -50 years 51+ years Total Actual Estimated Projected 2015 -16 2016 -17 2017 -18 180 180 200 335 335 350 515 515 550 300 300 325 495 495 540 500 500 560 195 195 215 500 500 530 0 0 0 5 5 20 495 495 540 500 500 560 Alamance County Chatham County Durham County Wake County Orange County Breakdown 250 250 350 Chapel Hill Public Housing Town of Chapel Hill (Non - Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) 150 150 200 50 50 55 325 325 350 125 125 130 500 500 530 Alamance County Chatham County Durham County Wake County Orange County Breakdown 250 250 350 Chapel Hill Public Housing Town of Chapel Hill (Non - Public Housing) Town of Carrboro Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) 150 150 200 50 50 75 50 50 75 PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 17 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Total 1 500 500 700 Work Statement b) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (.,Specific, Measurable, Achievable, _Relevant, and Time - bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly /disabled residents.) • Program Goal should explain what the program is trying to achieve /accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday- Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program 1. Program Activity Name Disaster Preparedness Program Goal To educate about the risks of personal surroundings, reduce risk Performance Measures Written statements about actions to be taken Previous Year Program Results 10 attendees Current Year Estimated Results 19 attendees Next Year Projected Results 25 attendees 2. Program Activity Name Affordable Housing Program Goal Provide ADA- compliant fair housing info to landlords and tenants Performance Measures Quizzes, self- assessment tools, and follow -up email Previous Year Program Results 17 Current Year Estimated Results 28 Next Year Projected Results 40 3. Program Activity Name Technology Literacy Classes for the Blind Program Goal Provide assistive technologies to aid in job placement Performance Measures Questionnaires that will be graded and course evaluations Previous Year Program Results 12 Current Year Estimated Results 15 Next Year Projected Results 22 4. Program Activity Name ADA Selected Topic Training Workshops Program Goal Improve access to public accommodations for the disabled Performance Measures Written statements, surveys, evaluations Previous Year Program Results 20 PROGRAM INFORMATION 2/9/2017 4:31:06 PM P a g e 18 of 2 2 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Current Year Estimated ReHilts 7 Next Year Projected Results 135 PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 19 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 6lA6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION c) Program Budget 1. Submit your program budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues • Private Donations • Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) • Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG /HOME /etc.) • Private Foundation Grants o Other Revenue Expenditures o Compensation o Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. 3. This program budget represents what percent of the agency budget? % 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 20 of 22 Actual 2015 -16 Estimated 2016 -17 Projected 2017 -18 Total Cost of Program $1,600.00 $1,600.00 $1,600.00 Total # of Individuals 7 7 7 Cost Per Individual $228.00 $228.00 $228.00 PROGRAM INFORMATION 2/9/2017 4:31:06 PM Page 20 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Salaries 24000 Office Supplies 2600 Printing 1000 Insurance 2200 Postage 900 Travel 750 Program Total $31,450 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION OCDAC Operating Budget Expenses Salaries 24000 Office Supplies 2600 Printing 1600 Insurance 2000 Postage 300 Travel 750 Revenue Grants Orange County 7,000 Town of Chapel Hill 4,000 Town of Carrboro 5,000 Stroud Roses 2,000 Agency Generated 1,500 Total Revenue Grants 19500 Revenue Workshops 4000 Revenue Donations 500 Total Revenue 24,000 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2015, for calendar year agencies, and FY 2015 -16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit /report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2014 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990 -N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Frequently Asked Questions Guide (PDF), about exemptions. If exempt per N.C.G.S. § 131 F -3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax - Exemption Letter A copy of the agency's IRS tax - exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of Liability Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note: If Approved for Funding: Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 — June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. DO NOT SUBMIT THIS PAGE 2/9/2017 4:31:06 PM Page 21 of 22 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 6lA6E4C39BD2 EXHIBIT A - PROVIDER'S OUTSIDE AGENCY APPLICATION Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Limits for Coverage Compensation' A - Statutory State Limits for Coverage A - Limits for Coverage A - NC, for each Statutory State NC, for Statutory State NC, for employee each employee each employee Limits for Coverage Limits for Coverage B - Limits for Coverage B - B - Employers Employers Liability of: Employers Liability of: Liability of: $100,000 Each Occurrence $500,000 each $1 million Each $100,000 BID for each accident, $500,000 Occurrence employee BID for each employee $1,000,000 BID $500,000 BID limit $500,000 for BID limit limit Commercial $100,000 Property General Damage Liability $1 million Each Occurrence $1 million Each Liability $1,000,000 Bodily $2 million Aggregate Occurrence Injury ry and Property $2 million Aggregate Damage Limit Automobile Liability Not Applicable $1 million Each Occurrence $500,000 Each Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts webpage for more information about the County's risk assessment procedures. f) List of Board of Directors Provide the following information about each board of director's member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. g) Solid Waste Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency's FY 2016 -17 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. DO NOT SUBMIT THIS PAGE 2/9/2017 4:31:06 PM Page 22 of 22 DocuSign Envelope ID: 07 FEE 1A8- E83F- 44CF- 99C4 -61 A6E4C39BD2 EXHIBIT "B" Scope of Services — FY 2017 -18 Outside Agency Performance Agreement Agency Name: Orange County Disability Awareness Council Program Name: Funding Award: 58250 Outline huw the agency will spend Orange County's funding award, Expense Description Amount Program Support Supplies — Human Interests Projects, Supplies, Staff Training, Computer Support, Travel and Printing. $8250 Affordable Housing 77 residents Computer Classes 22 residents Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30. 2018. ADA training workshops — Program addresses challenges that persons with disabilities face in pedestrian safety and community travel transition preparedness. Emergency Preparedness — Provide educational materials. lectures and safety kits to raise awareness about common safety risks. • Affordable Housing — The expectationi is prospective tenants will have the necessary content information and communications tools to readily identify housing discrimination and providers will have a clear sense of any deficiencies in their processes. Computer class for visually imparied — Classes wit provide information and trianing to area students with disabilities who are or soon will be entering high or higher education. Anticipated Outcomes I'hc Anticipated Results culuMn must include quantifiable results in the form of number of per',WN units served within Orauae ['aunty. un1► (all 'rowns and municipalities). If you use percentages, you must also provide [lie total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results I'T'llergency Preparedness 77 residents Affordable Housing 77 residents Computer Classes 22 residents DocuSigned by: SFSE OE BAZ37945B... Certified by: Executive Director 1/24/2018 D a t e/4 Ll� J--/� DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 ATTACHMENT "A" Orange County Certifications — FY 2017 -18 Outside Agency Performance Agreement Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title, residential address; phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing, with the name, physical address, mailing address and if possible, phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. Certified by: �.GceuSigned by: Executive Director 1/24/2018 8F530EBA237945B... Title: Date: (Provider's Signature) (OC Disability Awareness Council) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7117 DocuSign Envelope ID: 07FEE1A8- E83F- 44CF- 99C4- 61A6E4C39BD2 vucna�r. rvvav�.r 040RANGCOUl ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD /YYYY) 9/07/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER BB &T Insurance Services, Inc. 414 Gallimore Dairy Road Suite F Greensboro, NC 27409 CONTACT NAME: PHONE 888 743 -2217 FAX 8888279861 A/C, No, Ext : A/C, No E -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Alliance of Nonprofits Ins RRG 10023 INSURED Orange County Disability Awareness Council INSURER B: 09/14/2018 INSURER G $1,000,000 CLAIMS -MADE � OCCUR 503 West Franklin St #113 INSURER D: Chapel Hill, NC 27516 INSURER E: INSURER F: $ 500,000 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM /DD /YYYY POLICY EXP MM /DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 201729484 09/14/2017 09/14/2018 EACH OCCURRENCE $1,000,000 CLAIMS -MADE � OCCUR PREMISES ERENTED r nce $ 500,000 MED EXP (Any one person) $ 20,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PRO- LOC PRODUCTS - COMP /OPAGG $2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR /PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F7 N/A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Directors & 201729484D0 9/14/2017 09/14/2018 See Desc of Ops Officers DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Miscellaneous Coverage - Directors and Officers - Pol.# 201729484DO Directors and Officers Limit #1: 1,000,000 Limit #2: 1,000,000 II," a G. I I a Pfd. I in G Loll ,., R I10 Uf a A AG\ I PJ► Orange County Human Services PO Box 8181 Hillsborough, NC 27278 ACORD 25 (2014/01) 1 of 1 #S18735433/M18735429 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BD7