HomeMy WebLinkAbout2018-138 DSS - NCDSS training contract amendmentra p ( b5 11✓75
Contract Number00036254, Amom menl Number 1 / Pagel of 16
AMENDMENT
This Agreement amends the contract bearing the effective date of 10/112017 beWSed the North Carolina
Department of Health and Human Services, Division of Social SeMCes, hereinafter referred W as the
'Division' and Orange County Department of Social Services, hereinafter referred W as the ' Contractor."
This Amendment is hereby of eWe on 10 /112017.
As proNded for under the terms of this contract, the Division and the Contractor agree to amend the
following contract provisions:
1. Refe ence'Effective PedW: The lamination date of 9/30/2018 has not changed
2. Reference 'Contractors Dutles': The Contractor shall provide the amended seMces as
described In the scope of work.
3. Reference'DIMsion's Dutlee: The total amount paid by the Division to the Connector is being
Increased by $240,000 from $399,908 to $639,908. This amended amount consists of $0 In
State funds, $0 In Local funds, $0 in Other funds and $240,000 in Federal funds.
The Contractor's matching requirement for this amendment is $240,000. The total contractor's matching
amount Is $639,808.
The contributions from the Connector shall be sourced from non - federal furs.
The total amendment amount Is $480,000.
The total contad amount Is $1,279,816.
Other Requirements:
Other Requirements:
Continuation of 4. Canirectoes Duties:
Any contract amentlment, budget amendment, orrealignment must be submitted to the DSS
Contact Office by July 1.
This contact will be In compliance with the Federal Office of Management and Budget (OMB)
CFR The 2 Part 200 which may be accessed at hqc'1/www.ecfrqcv1coi-IbiMeA-
dx?bcI=hmA-brmasaoTftIeB212cft2OO man 02 tot.
Continuation of 5. OWlsion's Dudes:
Sub- redpient name: Orange County Department of Social Services
Sul -mcipkcnt DUNS Number. 088563762
Federal Awed Identification Number. 1716514C4062514 and 181 75NC4062614
NCDHHS ACT2007 (Amendment Template) (Rev. 11.01.15)
Contract Number 00036254, Amendment Number 1/ Page 2 of 16
Federal Award Date: FFY17 and FFY18
Sub-award Period of Performance Start and Ern! Date: 1WI117- 9/3 011 8
Amount of Federal Funds Obligated by this action: $639,908
Total Amount of Federal Funds Obligated to the sub- reciplent $639,908
Total Approved Cost Sharing /Matching: $639,908
Total Amount of the Federal Award: $98,902,746
Federal Award Project Description: FSP/SNAP Food & Nutrition Services: Education & Training
Name of federal awarding agency, pass- through entity and named Information for awarding
bill
United States Department of Agriculture, NO Department of Health add Human Services, Division
of Social Services, 919 -527 -6335
CFDA Number and Name: 10.W State Adminim etwo Matching Grants for Food Stamp Program
Award is R &D: No
Indirect cast rate for Federal award administrative cost limitation is N /A.
TralficYlna Victims Protection Act of 2000
This award Is subject to the requirements of Sedan 106(g) of the TraRCking Victims Protection
Act of 2000, as amended (22 U.S.C. 7104), go to: hgn,M/ .acf.hhc.00vlmantslaward-Lr anb
condition- for- trafficItinoin- oersons. The use of Federal funds from this award constitutes the
State's acceptance of Ness terms and conditions.
All other terns and conditions as set forth in the original comment document shall remain In effect for the
duramon of this Agreement.
Signatures follow on next page
NCDHHS ACT2007 (Amendment Template) (Rev. 11.01.15)
Contract Number 00036254, Amendment Number 1 / Page 3 of 16
In Witness Whereof, the Contractor and the Division have executed this contract in duplicate originals,
with one original being retained by each party.
Orange County Department of Social Services
P , v
Signature
Bonnie Hammersley
Printed Name
WITNESS
M&�)J--
Signature
- /31/62
Date
County Manager
Title
�13/1�
Date
�i �1 itn�ion R5 '=ncL �RtwflA Aar/
Printed Name Title
Services, North Carolina epartment of Health and Human Services
Date
Director
Title
NCDHHS ACT2007 (Amendment Template) (Rev. 11.0 1.15)
Contract Number 00036254, Amendment Number 1 / Page 4 of 16
SCOPE OF WORK
PURPOSE
To include overhead costs
Scope of Work (Rev. 06111)
MINAIIgJJr111AMM
This begins the line item budget for year 1
Contract Number 00036254, Amendment Number 1 I Page 5 of 18
Budget Detail -Year 1
Category
Item
Narrative
Original Amount
Change Amount
Final Amount
Salary\Wages
$195,000.00
$0.00
$195,000.00
Forge Benefits
$65,928.00
$0.00
$65,928.00
Omer
$0.00
$0.00
$0.00
Repair and Maintenance
$0.00
$0.00
$0.00
Staff Development
$0.00
$0.00
$0.00
Dues and Subscriptions
$0.00
$0.00
$0.00
Operational Omer
Incentives
and
Participants
$10,000.00
$0.00
$10,000.00
Operational Omer
Service
Payments
$20,000.00
$0.00
$20,000.00
Operational Other
Incentives
and
$6,230.00
$0.00
$6,230.00
Lire Item Budget Derail (08111)
Contact Number 00036250. Amendment Number 1 / Page 6 of 16
Budget Detail -Year 1
Category
Item
Narrative
Original Amount
Change Amount
Final Amount
Participants
OpeaOOnal Other
Inoanlives
-
$4,000.00
$0.00
$4,000.00
and
Parucheme
Operational Other
Not
Overhead Costs
$0.00
$240,000.00
$210,000.00
Otherwise
Classified
$480,00012= $240,000
Operational Mar
Incentives
$15,000.00
$0.00
$15,000.00
and
Participants
Operational Other
Incentives
$35,000.00
$0.00
$35,000.00
and
Participants
Subcontracts and Grants
$48,750.00
$0.00
$48,750.00
Match
Overhead! Costs
$399,908.00
$240,000.00
$639,900.00
$480,000/2= $240,000
Cost Per Service
$0.00
$0.00
$0.00
Sub Total
$799,816.00
$480,000.00
$1,279,816.00
Inllrectcos1
$0.00
$0.00
$0.00
Total Budget
$7 99,816.00
$480.00D.00
$1,279,816.00
Line Item Budget Detail (0811 t)
Contract Number 00030254, Amendment Number 1 / Page ] of 18
Subcontracting and Grants Budget Detail -Year1 -
Category
Item
Narrative
Original Amount
Change Amount
Final Amount
SalaMwages
$0.00
$0.00
$0.00
Fringe Benefits
$0.00
$0.00
$0.00
Other
$0.00
$0.00
$0.00
Repair and Maintenance
$O.00
$0.00
$0.00
Staff Development
$0.00
$0.00
$0.00
Dues and Subscriptions
$0.00
$0.00
$0.00
Suboontmas and Grants
$0.00
$0.00
$0.00
Indirect Coat
$0.00
$0.00
$0.00
Coat Per Service
$0.00
$0.00
$0.00
Operational Other
Not
Othervvse
$48,750.00
$0.00
$48,750.00
Line Item Budget Detail (08/11)
Contract Number 00038254, Amendment Number t I Page 8 of 18
Subcontracting and Grants Budget Detail -Year 1
Category
Item
Narrative
OrigmalAmount
Change Amount
Final Amount
Fringe
Amount Total
Classifie0
Total
o
Mau
Sub Total
$48,750.00
$0.00
$48,750.00
Salarles Year I
Persons
Position or Title -
Annual Salary
Hourly
Rate
Months
Mrs 9%
Fringe
Amount Total
Fringe
Percent Total
Total
o
Mau
a.omo
I 0
1 0%
1 $a.oa
$0.00
$a.m
Line Item Budget Delail (08111)
Contract Number 00036254, Amendment Number 1 I Page 9 of 16
FEDERAL CERTIFICATIONS
The undersigned slat" that:
I. He or she is the duly authorized representative of the Contmctornamed below;
2. He or she is authorized to make, and does hereby make, the fallowing certifications on behalf ofthe Convector, as act
out herein:
a. The Certification Regarding Nondiscrimination;
b. The Codification Regarding Dmg -Fm Workplace Requirements;
c. The Certification Regarding Environmental Tobacco Smakr,
d. The Codification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered
Transactions; and
e. The Certification Regarding Lobbying;
3. He or she has completed the Codification Regarding Drug-Frce Workplace Requirements by providing the addresses
at which the contract work will be performed;
4. [Check the applicable statement]
❑ He or she has completed the attached Okclosurc of Lobbying Activities because the Contractor has made, or
has an agreement to make, a payment to a lobbying entity for influencing or attempting to influence on olDar
or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with a covered Federal action;
OR
® He or she has not completed the attached Disclosure of Lobbying Activities because the Contractor has not
made, and has no agreement to make, any payment to any lobbying entity for influencing or attempting to
influence any officer or employee of any agency, any Member of Congress, coy officer or employee of Congress,
or any employee are Member ol'Congress in connection with a covered Federal action.
5. The Contractor shall require its subcontractors, if any, to make the same certifications and disclosure.
Chance CommV Department Of SnCal Services --
ConlractorlDrgaolmtian 'sl Legal Nome Date
ink Certification must W slgacd by n representative of the Contractor who is authorized to sign contracts.]
1. Codification Regarding Nondiscrimination
The Contractor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are
net limited to: (o) Title VI of the Civil nights Act of 1964 (P.L. 88 -352) which prohibits discrimination an the basis of
race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. § §1681 -1683,
and 1685 - 1686), which prohibits discriminotion on the bask of sex; (c) Section 504 of the Rehabilitation Act of 1973, as
amended (29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of
1975, as amended (42 U.S.C. § §6101 -6107h which prohibits discrimination on the basis of age; (e) the Drug Abuse
office and Treatment Ad of 1972 (P.L. 92 -255), as amended, relating to nondiscrimination on the basis of dreg abuse; (f)
the Comprehensive Alcohol Abuse and Alcoholism Provender, Treatment and Rehabilitation Act of 1970 (P.L. 91.616h
as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Title VIII of the Civil Rights
Act of 1968 (42 U.S.C. § §3601 at segJ, m amended, relating to nondiscrimination in the sale, mortal or financing of
housing; (h) the Food Slump Act and USDA policy, which prohibit discrimination on rite basis of religion and political
beliefs; and the requirements crony tuber nondiscrimination solutes which may apply to this Agreement.
Contract Number 00036254, Amendment Number 1 I Page 10 of 16
If. Certification Regarding Drug -Free Workplace Requi vni
I. The Contractor certifies that it will provide a drug -frte 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 Contractor's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
b. Establishing a drug -fret awareness program to inform employees about:
(1) The dangers ofdrug abuse in the workplace;
(2) The Connector's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
c. Making it a requirement that each employee be engaged in the performance of the spectrum be given a copy
of flue statement required by pwgmph (a);
d. Notifying the employee in the statement required by paragraph (a) Nnq as a condition of employment under
the agreement. the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug stands conviction for a violation counting in the
workplace no Inter than five days after such conviction;
c. Notifying the Department within ten days after receiving notice under subparagraph (d)(2) from an
employee or otherwise receiving school notice of such conviction;
f. Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), with
aspect to my employee who is so convicted:
(I) taking appropriate personnel action against such an employee, up to and including
tarmination; or
(2) Requiring such employee to po ilcipahe satidrecmrily 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, and
g. Making a good faith effort to continua to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and (Q.
2. The sites for the performance of work done in connection wills Nc specific agreement are listed below (list all
sites; add additional pages if naessary):
Street Address No. 1:113 Mayo Street
Chy Stoic, Zip Cade: Hillsborough INC 27278
Street Address No. 2: 2501 Homestead Road
airy, state, Zip Cade: Charoul Hill NC 27516
Contract Number 00036254, gqmis dm nt Number i/P ge 11 of 16
3. Contractor will inform the Department of any additional thus Forperformonce ofwar�t on�erthesngreemen..
4. False certification or violation of the certification may be grounds for suspension of payment, suspension or
termination ofgmnts, orgovemment -wide Fedcml suspension or debarncnf. 45 C.F.R.83.510.
Ill. Certification Regarding Environmental Tobacco Smoke
Public Uw 103 -227, Part C- Environmental Tobacco Smoke, also known as the ProChildmn Act of 1994 (Act), requires
that smoking not be permitted in any portion crony indoor facility owned or leased or connected for by an entity and used
routinely or regularly for the prevision of health, day care, education, or library services to children under the age of Ia, if
the services are funded by Federal programs either directly or through Stale or local governments, by Federal grant,
contract, loan, or loan guarantee. The law does not apply to childrenb services provided in Private residences, facilities
funded solely by Medium or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment.
Failure to comply with die provisions of the law may result in the imposition of a civil monetary penalty of up a
$1,000.00 per day and/or the imposition area administrative compliance order on the responsible entity.
The Contractor certifies that it will comply with the requirements of the Act. The Contractor fuller agrees that it will
require the language of this unification be included in any subawards that contain provisions for children's services and
that all subgranlees shall certify accordingly.
IV. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Excitation fewer Tier
Covered Transactions
Instructions
(The phrase "prospective lower tier participate' means the Contractor.]
I. By signing and submitting this document, the prospective lower tier participant is providing the certification set
out below.
2. The certification in this clause is a material representation of the fact upon which reliance was placed when this
=section was emend into. If it is later determined that the prospective lower tier participant knowingly
rendered an erroneous certification, in addition to other remedies available to the Federal Government, the
department or agency with which this transaction originate may pursue available remedies, including suspension
and/or debarment.
3. The prospective lower tier participant will provide immediate written notice to the person to whom this proposal
is submitted if at any time the prospective lower tier participant teams that its certification was consumer when
submitted or has become erroneous by reason of changed circumstances.
4. The terns "covered formation," "debarred;' "suspended," "ineligible," "lower tier covered transaction;'
"participant." 'busiaq" "primary covered transaction;' "principal;' "proposal," and "voluntarily excluded," as
used in this clause, have the meanings act out in the Definitions and Coverage sections of rules implementing
Executive Order 12549, 45 CFR Part 76. You may contact the person to whom this proposal is submitted for
assistance in obtaining a copy of those regulations.
S. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered
transaction be enured info, it shall not knowingly enter any lower tier covered transaction with a person who is
debarred, suspended, determined ineligible or voluntarily excluded from participation in this covered transaction
unless authorized by the department or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this document that it will include the clause
titled "Ceri fication Regarding Debarment, Suspension, Imligibilky and Voluntary Exclusion —Lower Tier
Covered Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower
tier covered transactions.
7. A participant in a covered elimination may rely upon a certification of a prospective participant in a lover tier
covered transaction that if is no debarred, suspended, ineligible, or voluntarily excluded Iran covered
transaction, unless it knows that the certification is erroneous. A penicipanl may decide the method and frequency
by which it determines the eligibility of its principals. Each participant may, but is not required to, check the
Nonprocurement List.
Contract Number 00036254 ,Amendment umbe 1.1 Pa a 20116
I. Nothing contained in the foregoing shall be comment to require establishment of a system a orbs in a er a
render in goad faith the codification required by this clause. The knowledge and information of a participant is
not required to exceed that which is normally possessed by a.prudenl person in the ordinary course of business
dealings.
9. Except for Interactions authorized in paragraph 5 of these instructions, if a participant in a covered transaction
knowingly enters into a lower tier covered Instruction with a person who is suspended, debarred, ineligible, or
voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal
Goverment, the department or agency with which this transaction originated may pursue available remedies,
including suspension, and/or debarment.
Certification
0. The prospective lower tier participant eertiflm, by submission of this document, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded
from participation in this transaction by any Federal department or agency.
b. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such
prospective participant shall attach an explanation to this proposal.
V. Certification Regarding Lobbying
The Contractor certifies, to the best of his or her knowledge and belief, that:
I. 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 or any agency, a Member of Congress, an officer
or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any
Federal contract, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or
cooperative agreemenL
2. Ifany 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, on officer or employee of
Congress, or an employee of Member of Congress in connection with this Federally funded contract, grant, loan,
or cooperative agreement, the undersigned shall complete and submit Standard Form SF -LLL, "Disclosure of
Lobbying Activities," in accordance with its instructions.
3. The undersigned shall require that the language of this certification be included in the award document For
subawards at all liars (including subcontracts, subgranls, and contracts under grants, loans, and cooperative
agreements) who receive federal funds of 5100,000.00 or more and that all subrocipients shall comfy and disclose
accordingly.
4. This certification is a material representation of fact upon which mliance was placed when Wis connection 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 certification shall be
subject u aeivil penalty often less than 510,000.00 and not more than $100,000.00 foreach such failure.
W. Disclosure of Lobbying Activities
Instructions
This disclosure font shall be completed by the reporting entity, whether suhmvardee or prime Federal recipient, at the
initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C.
section 1352. The riling are form is required for each payment or agreement to make payment to any lobbying entity 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 a covered Federal action. Use the
SF -LLL-A Continuation Sheet for additional information if the space on the fort is inadequate. Complete all items that
apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of
Management and Budget Far additional information.
Contract Number Q0006204 An nndment Neu nth inHuenc�e�� of 16
1. Identify the type of covered Federal action far which lobbying activity Is andd // r has n secure 0
outcome of covered Federal action.
2. Identify Ne status aftho covered Federal action.
3. Identify the appropriate clossibcation of this rerun. If this is a follow -up report caused by a material change to the
information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last
previously submitted report by this reporting entity fw this covered Federal action.
4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known.
Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or sub.
award recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards
Include but are not limited to subcontracts, subgrems and contract awards under grams.
5. If the organization riling the mpon in Item 4 checks "Subawardee ", than enter the full name, address, city, state and
zip code of the prime Federal recipient. Include Congressional Distric4 if known.
6. Enter the name ordw Federal agency making the award or loan commitment. Include at least one organizational level
below agency name, if known. For example, Department ofTmnspartation, United Stales Coast Guard.
7. Enter the Federal program name or description for the Covered Federal action (Item I). If known, enter the full
Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan
commitments.
S. Enter the most appropriate Federal Identifying number available for the Federal action identified in Item 1 (e.g.,
Request for Proposal (RFP) number, Invitmton for Bid (IFB) number, grant announcement number, the contract grant,
or loan award number, the application/proposal control number assigned by the Federal agency). Include Prefixes,
e.g., "RFP- DE40 4)01:'
9. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the
Federal amount of the award/loan commitment for the prime entity identified in Item 4 or 5.
lo. (a) Enter the full name, address, city, state and zip Code of the lobbying entity engaged by the reporting entity
identified in Item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a).
Enter Last Name, First Name and Middle Initial (Mp.
11. Enter the amount of comraboution paid or reasonably expected to be Paid by the reporting entity (Item 4) to the
lobbying entity (Item 10). Indicate whether the payment has been made (acmap or will be made (planned). Check all
boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be
MAC.
12. Check the appropriate boxes. Check all bolts that apply. Ifpayment is mode through an in -kind contribution, specify
the nature and value ortbe in -kind payment.
13. Check the appropriate boxes. Check all boxes that apply. If other, specify nature.
14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to
perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in
actual Contact with Federal officials. Identify the Federal officials) or employce(s) Connected or the officer(s),
employee(s), or Member(s) ofCongrass that were contacted.
15. Check whether or net a SF -LLL -A Continuation Sheets) is attached.
16. The certifying official shall sign and date the form, print hislher name, title, and telephone number.
Disclosure of L(dbtOag 4MMOM254, Amendment Number 11 Page 14 of 16
(Approved by OMB 03460046)
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
1. Type of Federal Action :
2. Sttusal FederelAction:
3. Report Type:
❑ a. assured
❑ a. BidNRer /applbafia
❑ a. Inifalgllrg
b Award
❑ terial change
b. ma
• c. coepealive agreement
❑ . Post Aware
❑ d. loan
For Malarial Change Only:
[3 e loan
❑ C loan Insurance su ance
Year Ouader
Dab of Lae Rep�
4. Name and Address of Repodtng Entity:
S. tReponng Entityln NO.4ls EUbavardee,Bnbr Name
❑ Pdme
and Address of Prime:
❑ SubewaNee Tier_, ofisoan)
Congressional Dbbid It known
Can restone Dishkt If gravel I
T. Federal Progress NamauDesagtbr:
6. Federal DepaumentlAgenar:
CFDA Number Of appliable)
B. Federal Action Number (it knmvn)
9. Award Amount(R known):
E
10, e. Name as Lobbying
b. tedleteuate Servl®ame.priMga
kAkee, hat e, hislrenl
(NIntllWtlal, bar rame,Me oams, MS:
IN
nNor 10h "am,
b'Rersnl from NO lOa) panorama,! mama, MS:
(SHOW COnf Ulvn SMa1(eI SFCL Aifnxeaary)
(WISCIP cold Oadow EMORS) MoULA, amces MA
11. Amount of Payment bobeor 0that apply):
13. Type of Payment bugook all that apt
g actual planned
❑ a retainer
❑ b. one -Gore fee
❑ c. commission
12. Form of Payment (check at/ Mat apply):
❑ d. comngentba
❑ a. cash
❑ e. deferr ed
❑ b. In defspecify: beat.
❑ f. oPer,spedry:
Value
14. Bdel Description of Servicas Performed or to be Performed and Dealt) of Serdws, indudag ofhoe ), empbyee(5), or
Member(s) palacted for Payment Indicated In Item Masson Caucasian Shoed(n) MF A,Rnrwssyl:
15. Contraction Sheens) SF -U-LA injuries: ❑ Yea ❑
NO
16. Information requested drought this farm is authorized by
Signore:
tide 31 U. S. C. section 1352. TWO disclosure of lobbying
waddled is a materbl representation of roar upon which
reliance was placed by Pe tar above when this Inspection
Pont Nave:
was made or entered into TWO disclosure Is required
pursuant b 31 U. S. C. 1352 This information we bas
Toe:
recorded 0 Me Congress uml-anraally and will be
available ter public Inspection. My person who thMS W die
Telephone NO: Dale:
Oise required dbdasure shall be subject to acivll penalty of
not less than $10, W e aM trod mom Nan S 100.000 for each
such failure.
Federal Use Only
Mlhodaetl fa Leal
Repaductim
Standard Form -=
Public winning When for INS mseco n OI iniarmthon Is consoled b erwa9e an manor per response, Indian" was fw reubMig Nalmtlbm.
watching eWWg data souses, gathering wk maintaining the data Mai ON emission and massive the mauled 0 inlomatbn. Shad
comments regaabp the When engines or any apes aspect of this mission of lnbnmtiM. convig sv;9alwns Itt stocks Ph laden, b IM
dfire of Manamnent and &WOel. l+emmma Red od on Pmiect (DUB-D046). Washington. D. C. 20500 _
State Ch$4111Rfi'1"ther 00036254, Amendment Number 11 Page 15 of 16
Contractor Certifications Required by North Carolina few
Instructors: The person who signs this document should mid the text orlhe slamles and Execidwe Order had below and consult
with camel and other knowledgeable persons before signing. The text of can North Carelia General Statutes and or the Excativc
Omer an be road online al:
• Aniek2ol'Chan"64: hap /Iwww.n gnnak. nc. uJ[ noa< EL< 6iabtianl5mtmevl 'DFIOYAnid<MM1Vq <r 6llAnkle 2.pdf
• G.S. 13342: htryl/ www. ncgaaak. nnu9ausmiPWamm <YSamehwkupDHaaute 133 -32
• Execan Order No. 24 O calm, Gov., Oct 1, 2009): mtp: /l www. ethicxommiuian .nc.govll3wy/pdmAg E024.pdf
• GS. 105- 164.8(6): M1npdM+vw.nzp.sum.nmu EnxtvdlsglslOLi d mlote DFMySccti MPlm_IOS/GS_ 105.164. h.pdr
• G.S. 14348.5: hupd/ wwwn< gutv¢. nc. orlEnuncdL< PislvtiWSlvmkeM1rfM1J9y5eNON CM1Vptcr NLGS 1434&51ml
• G.S. 14339.1: M1np// mnv. maomPle. rc. uyEnvnmL< eialmivNSlam¢ vPDFl0y8mioNChopler .,HLG514L59.I4Mf
• G.S. 143 -59.2: Mtp!/ www. mgoeom. nc. uslEnn ct< JL< glslotioMauteslpDF /OYSeaION[hvPtv_L43MS 14349.2pdr
• G.S. 143- 1333: http /Iwww.n<6asvt<. noes/[ nvaedLglsldioNStwuksli11M1 /BySmicNChgaer_ 1431GS 143-133.3.himl
• G.S. 1438.139.6C: hupl/ www. ncgnuvk. n<. uf/[ nu¢ dLegislvtivNSmmuxtPDplpyScnivNCNp <r 1430PoS_I4ID.II9.bC.pdf
Certifications
(1) Pungent to G.S. 13342 and Executive Order No. 24 after December 31, 2001 but the United States
(Pardon, Gov., Ocl. 1, 2009), the undersigned hereby is not the principal market for the public trading
certifies that the Contractor named below is in of the stack of the corporation incorporated in
compliance with, mid has not violated, the previsions of the tax haven country.
either said statute or Executive Order. (4) pursuant to G.S. 143.59.2(b), the undersigned hereby
(2) Personal to G.S. 14349.5 and G.S. 143 - 133.3, the artiftes that Atone of the COn[nLlor's officers,
undersigned hereby certifies that the Connscor named directors, or owners (if the Contractor is an
below, and the Contractor's subcontractors, complies unincorporated business entity) has been convicted of
with the requirements of Article 2 of Chapter 64 of the any violation of Chapter 79A of the Gem ml Statutes or
NC General Sautes, including the requirement for the Securities Act of 1933 or the Securities Exchange
such employer with more than 25 employ=$ in North Act of 1934 within 10 years immediately prior to the
Carolina to verify the work authorimtian of its date of the bid solicitation.
employees through the federal E- Verify system." E- (5) Pursuant to C.S. 1430- 139AC, the undersigned
Verity System Link: www lscis eov hereby certifies that the Contractor will not use o
(3) Pursuant to G.S. 143 - 59.1(6), the undersigned hereby former employee, as defined by G.S. 1430 -
certifies that the Contractor named below is not an 139.6C(d)(2), of the North Carolina Department of
'ineligible Contractor' m set forth in G.S. 143 - 59.1(x) Health and Human Services in the administration era
because: contract with the Department in violation of G.S.
(a) Neither the Contractor nor any of its affiliates has 1430- 139.6C and that a violation of that statute shall
refused ID collect the use tax levied under Article 5 void the Agreement.
of Chapter 105 of the General Statutes on its aim (6) The undersigned hereby certifies further dint:
delivemd to North Carolina when the sales met (a) He or she is a duly authorized representative of the
one or more of the conditions of G.S. 105- Conereclor named below,
164.8(6); and (b) He or she is authorized to make, and does hereby
(b) [check one of the following boxes] make, the foregoing certifications on behalf of the
® Neither the Counselor nor any of its affiliates Contractor, and
has incorporated or reincorporated in a Wax (c) He or she understands that any person who
haven country" as at forth in G.S. 143- knowingly submits o false ariffcation in responom
59.1(c)(2) after December 31, 2001; or to the requirements of G.S. 143- 59.1and .59.2
O The Contractor at one of its affiliates has shall be guilty era Class l felony.
incorporated or reincorporated in a "lax haven
country" as set forth in G.S. 143-59.1(c)(2)
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF SOCIAL SERVICES
Roy COOPER
GOVERNOR
April 24, 2018
Rebekah Rapoza, Management Analyst
Orange County Department of Social Services
113 Mayo Street, P.O. Box 8181
Hillsborough, NC 27278 -2573
MANDY COHEN, MD, MPH
SECRETARY
WAYNE E. BLACK
SR.DIRECIoRoFSoc=SERVTCas
ANO COI OPERATIONS
Re: Orange County Department of Social Services Employment & Training - DSS Contract Amendment #36254
Dear Ms. Rapoza:
Enclosed is your fully executed copy of the contract amendment # 1 between the Division of Social Services and your
agency for the period of October 1, 2017 through September 30, 2018.
During the contract period, if you have any questions please contact me at 919 -527 -6256.
Please be advised that amendments cannot be accepted if they are beyond 120 days prior to the termination date of the
contract.
Sincerely,
Tanieka Robinson
Contract Administrator
Attachment (1): DSS Contract Amendment #36254
WWW.NCDHHS.GOV
TEL 919-527-6300 -FAX 919- 334 -1265
LOCATION: 820 S. BOYLAN AVE. • MCBRYDE BULDINO • RALEIGH, NC 27603
MAILING ADDRESS: 2420 MAn, SERVICE CENTER • RALEIGH, NC 27699 -2401
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EWLOYER