HomeMy WebLinkAbout2018-254 DSS - DHHS contract amendment #3Contract Number 00036254, Amendment Number 2 / Page 1 of 17
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AMENDMENT
This Agreement amends the contract bearing the effective date of 10/1/2017 between the North Carolina
Department of Health and Human Services, Division of Social Services, hereinafter referred to as the
"Division" and Orange County Department of Social Services, hereinafter referred to as the "Contractor."
This Amendment is hereby effective on 111/2018.
As provided for under the terms of this contract, the Division and the Contractor agree to amend the
following contract provisions:
1. Reference "Effective Period ": The termination date of 9/30/2018 has not changed
2. Reference "Contractor's Duties ": The Contractor shall provide the amended services as
described in the scope of work.
3. Reference "Division's Duties ": The total amount paid by the Division to the Contractor is being
decreased by $- 48,750 from $639,908 to $591,158. This amended amount consists of $0 in
State funds, $0 in Local funds, $0 in Other funds and $48,750 in Federal funds.
The Contractor's matching requirement for this amendment is $48,750. The total contractor's matching
amount is $591,158.
The contributions from the Contractor shall be sourced from non - federal funds.
The total amendment amount is $- 97,500.
The total contract amount is $1,182,316.
All other terms and conditions as set forth in the original contract document shall remain in effect for the
duration of this Agreement.
Signatures follow on next page
NCDHHS ACT2007 (Amendment Template) (Rev. 11.01. 15)
Contract Number 00036254, Amendment Number 21 page 2 of 17
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
a=.
Signature Date
Donnie Hamrnersley
Printed Name
WITNESS
Signa r
- /- ZA,,
Printed Name
County Manager
Title
Date
A5f �7')"
Title
Division of Social Services, North Carolina Department of Health and Human Services
Signature
Wayne Black
Printed blame
Date
Director
Title
NCDHHS ACT2007 (Amendment Template) (Rev. 11 O 1. 15)
Contract Number 00036254, Amendment Number 2 / Page 3 of 17
DIRECT CLIENT SERVICES CONTRACT
CONTRACTOR INFORMATION
Contract Agency Name Orange County Social Services
Address P.O. Box 8181
City, State, Zip Code Hillsborough, NC 27278
Tel #: 919 - 245 -2817 Fax #: 919 - 643 -4024 Email: lshewmaker(&,orangecountync.gov
Name: Bombe Hammersley
Signature Authority Title: County Manager
Address (if different from above)
City, State, Zip Code
Tel #: 919 - 245 -2306 Fax #: 919 - 643 -4024 Email: bhammersleynorangecountync.gov
Contractor Name: Rebekah Rapoza
Administrator Title: Management Analyst
Address (if different from
above)
City, State, Zip Code
Tel #: 919 - 245 -2869 Fax #: 919 - 644 -3058 Email: rrapozagorangecountync.goy
Program Name: Robert Gilmore
Administrator Title: Human Services Supervisor
Tel #: 919 - 245 -2847 Fax #: 919- 644 -3317 Email: rgilmore &,orangecountync.goy
Financial Name: Micah Guindon
Contact Title: Fiscal and Data Manager
Tel #: 919 - 245 -2803 Fax #: 919- 644 -3005 Email: mguindon(2orangecount3nc.gov
Name of Program(s): Food & Nutrition Services Employment and Training
Status: ® Public ❑ Private, Not for Profit ❑ Private, For Profit
Contractor's Financial Reporting Year: October 2017 — September 2018
SERVICE DELIVERY SITE(S): 113 Mayo St., Hillsborough; 503 W. Franklin St., Chapel Hill
AREA TO BE SERVED: Orange County
AGENCY WEBSITE: www.oran ecoun nc. oy
Contract Number 00036254, Amendment Number 2 / Page 4 of 17
SERVICES TO BE PROVIDED
(2)
(3)
(4)
(1)
Service
# of Persons
# of Units
(5)
Service
Code
Served
of Service
Definition of Service
Assessment of participant's
skill level, aptitude,
interests and supportive
Assessment
N/A
500
N/A
service needs.
Job seeking participants
make inquiries to
prospective employers
concerning employment
opportunities over a
Job Search
N/A
300
N/A
specified period of time.
Job seeking techniques to
enhance job readiness of
Job Search Training
N/A
300
N/A
participants.
Activities that improve
basic skills and the
Basic Education
employability of
Training
N/A
60
N/A
participants.
Skills training
workshops /classes leading
to obtainment of a
certification in a certain
Vocational Education
N/A
192
N/A
trade or craft.
Job training services that
are developed, managed,
and administered by State
agencies, local
govermnents, and the
business community -under
the Workforce Innovation
Workforce Innovation
and Opportunity Act
and Opportunity Act
N/A
48
N/A
WIOA).
Follow -up provided to offer
participants services up to
90 days after employment
90-Day Job Retention
N/A
300
N/A
is obtained via FNS E &T.
Contract Number 00036254, Amendment Number 2 / Page 5 of 17
SCOPE OF WORK
BACKGROUND
No change
PURPOSE
The purpose of this amendment is to remove the Education Navigator position — salary and fringes
(Durham Tech Subcontract) effective January 1, 2018.
PERFORMANCE REQUIREMENTS
During the period of January 1, 2018 through September 30, 2018 in the designated service area(s), the
Contractor, Orange County Department of Social Services, shall:
Provide education, training, and employment services to 300 recipients of FNS benefits who volunteer for
the E &T Program.
PERFORMANCE STANDARDS
No change
PERFORMANCE MONITORING / QUALITY ASSURANCE
No change
REIldBURSEMENTS
No change
DATA PRIVACY AND SECURITY
No change
CONFIDENDULITY
No change
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
No change
OVERSIGHT
No change
LINE ITEM BUDGET
This begins the line item budget for year 1
Contract Number 00036254, Amendment Number 2 / Page 6 of 17
Budget Detail - Year 1
Category
Item
Narrative
Original Amount
Change Amount
Final Amount
Salary \Wages
$195,000.00
$0.00
$195,000.00
Fringe Benefits
$65,928.00
$0.00
$65,928.00
Other
$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 Other
Incentives
and
Participants
$6,230.00
$0.00
$6,230.00
Operational Other
Incentives
and
Participants
$10,000.00
$0.00
$10,000.00
Operational Other
Service
Payments
$20,000.00
$0.00
$20,000.00
Line Item Budget Detail (08/11)
Contract Number 00036254, Amendment Number 2 / Page 7 of 17
Budget Detail - Year 1
Category
Item
Narrative
Original Amount
Change Amount
Final Amount
Operational Other
Incentives
and
Participants
$15,000.00
$0.00
$15,000.00
Operational Other
Not
Otherwise
Classified
$240,000.00
$0.00
$240,000.00
Operational Other
Incentives
and
Participants
$35,000.00
$0.00
$35,000.00
Operational Other
Incentives
and
Participants
$4,000.00
$0.00
$4,000.00
Subcontracts and Grants
$48,750.00
$- 48,750.00
$0.00
Match
$639,908.00
$- 48,750.00
$591,158.00
Cost Per Service
$0.00
$0.00
$0.00
Sub Total
$1,279,816.00
$- 97,500.00
$1,182,316.00
Indirect Cost
$0.00
$0.00
$0.00
Total Budget
$1,279,816.00
$- 97,500.00
$1,182,316.00
Line Item Budget Detail (08/11)
Contract Number 00036254, Amendment Number 2 / Page 8 of 17
Subcontracting and Grants Budget Detail - Year 1
Category
Item
Narrative
Original Amount
Change Amount
Final Amount
Salary \Wages
$0.00
$0.00
$0.00
Fringe Benefits
$0.00
$0.00
$0.00
Other
$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
Subcontracts and Grants
$0.00
$0.00
$0.00
Indirect Cost
$0.00
$0.00
$0.00
Cost Per Service
$0.00
$0.00
$0.00
Operational Other
Not
Otherwise
$48,750.00
$48,750.00
$0.00
Line Item Budget Detail (08/11)
Contract Number 00036254, Amendment Number 2 / Page 9 of 17
Subcontracting and Grants Budget Detail - Year 1
Category
Item
Narrative
Original Amount
Change Amount
Final Amount
Fringe
Amount Total
Classified
Total
0
$0.00
Sub Total
$48,750.00
$48,750.00
$0.00
Salaries -Year 1
Persons
Position or Title
Annual Salary
Hourly
Rate
Months
Work %
Fringe
Amount Total
Fringe
Percent Total
Total
0
$0.00
0.0000
0
0%
$0.00
$0.00
$0.00
Line Item Budget Detail (08/11)
Contract Number 00036254, Amendment Number 2 / Page 10 of 17
FEDERAL CERTIFICATIONS
The undersigned states that:
1. lie or she is the duly authorized representative of the Contractor named below;
2. Fie or she is authorized to make, and does hereby make, the following certilcations on behalf of the Contractor, asset
out herein:
a. The Certification Regarding Nondiscrimination;
b. The Certification Regarding Drug -Free Workplace Requirements;
c. The Certification Regarding Environmental Tobacco Smoke;
d. The Certification Regarding Debarment, Suspension, ineligibility and Voluntary Exclusion lower Tier Covered
Transactions; and
e. The Certification Regarding Lobbying;
3. Ile or she has completed the Certification Regarding Drug -Free Workplace Requirements by providing the addresses
at which the contract work will be performed;
(Check the applicable statement]
❑ Ile or she has completed the attached Disclosure 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 an officer
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
® Ile or she fins not completed the attached Disclosure of Lobbying Activities because (lie 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, any officer or employee of Congress,
or any employee of a Member of Congress in connection with a covered Federal action.
5. The Contractor shall require its subcontractors, if any, to make the same certifications and disclosure.
Signature
Title
OgAgg County Department of Socia) Services_ Q�cto r Ibg 2, 2011---
Contractor (Organization's) Legal Name Date
(This Certification must be signed by a representative of the Contractor who is authorized to sign contracts.)
1. Certification Regarding Nondiscrimination
The Contractor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are
not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88 -352) which prohibits discrimination on 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 discrimination on the basis 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 - 6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse
Office and Treatment Act of 1972 (P.L. 92 -255), as amended, relating to nondiscrimination on the basis of drug abuse; (f)
the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91 -616),
as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Title Vill of the Civil Rights
Act of 1968 (42 U.S.C. § §3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of
housing; (h) (lie food Stamp Act and USDA policy, which prohibit discrimination on (lie basis of religion and political
beliefs; and (i) the requirements of any other nondiscrimination statutes which may apply to this Agreement.
Contract Number 00036254,.Amendment Number 2 / Page 11 of 17
I11. Certification Regarding Drug -Free Workplace Requirements
1. The Contractor certifies that it will provide a drub -free workplace by:
a. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession or use of a controlled substance is prohibited in the Contractor's workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
b. Establishing a drub -free awareness program to inform employees about:
(1) The dangers of drub abuse in the workplace;
(2) The Contractor'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 agreement be given a copy
of the statement required by paragraph (a);
d. Notifying the employee in the statement required by paragraph (a) that, as a condition of employment tinder
the agreement, the employee will:
(1) Abide by the terms of the statement; and
(2) Notify the employer of any criminal drug statute conviction for a violation occurring in the
workplace no later 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 actual notice of such conviction;
f. Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(2), with
respect to any employee who is so convicted:
(1) taking appropriate personnel action against such an employee, up to and including
termination; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State, or local health, law enforcement, or
other appropriate agency; and
b. Making a good faith effort to continue to maintain a drub -free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and (f).
2. The sites for the performance of work done in connection with the specific agreement are listed below (list all
sites; add additional pages if necessary):
Street Address No. 1: 113 Mavo Street
City, State, Zip Code: Hillsborough. NC 27278
Street Address No. 2: 2501 Homestead Road
City, State, Zip Code: Chapel Hill, NC 27516
Contract Number 00036254, Amendment Number 2 / Page 12 of 17
Contractor will inform the Department of any additional sites for performance of work under this agreement.
False certification or violation of the certification may be grounds for suspension of payment, suspension or
termination of grants, or government -wide i-ederaI suspension or debarment. 45 C.F.R. 82.510.
111. Certification Regarding Environmental Tobacco Smoke
Public Law 103-227, Part C- Environmental Tobacco Smoke, also known as the Pro- Children Act of 1994 (Act), requires
that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used
routinely or regularly for the provision of health, day care, education, or library services to children under the age of 18, if
the services are funded by Federal programs either directly or through State or local governments, by Federal grant,
contract, loan, or loan guarantee. The law does not apply to children's services provided in private residences, facilities
funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment.
Failure to comply with the provisions of (lie law may result in the imposition of a civil monetary penalty of up to
$1,000.00 per day and /or the imposition of an administrative compliance order on the responsible entity.
The Contractor certifies that it will comply with the requirements of the Act. The Contractor further agrees that it will
require the language of this certification be included in any subawards that contain provisions for children's services and
that all subgrantees shall certify accordingly.
IV. Certification Regarding Debarment, Suspension, ineligibifity and Voluntary Exclusion Lower Tier
Covered Transactions
Instructions
[The phrase "prospective lower tier participant" means the Contractor.]
1. 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
transaction was entered 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 learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
4. Tile terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction,"
"participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as
used in this clause, have the meanings set 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.
5. Tile prospective lower tier participant agrees by submitting this proposal that, should the proposed covered
transaction be entered into, 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 "Certification Regarding Debarment, Suspension, ineligibility and Voluntary Exclusion- -Lower Tier
Covered Transaction," without modification, in all tower tier covered transactions and in all solicitations for lower
tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from covered
transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency
Contract Number 00036254, Arnendment Numbe I P 1 of 17
by which it determines the eligibility of its principals. I=.aeh participant may, taut is not required �o, cliccl:ie
Nonprocuremcnt List.
R. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to
render in good faith the certification required by this clause. The knowledge and information of a participant is
not required to exceed that which is normally possessed by a prudent person in (lie ordinary course of business
dealings.
9. Except for transactions authorized in paragraph 5 of these instructions, if a participant in a covered transaction
knowingly enters into a lower tier covered transaction 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
Government, the department or agency with which this transaction originated may pursue available remedies,
including suspension, and.ror debarment.
Certification
a. The prospective lower tier participant certifies, 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:
1. No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer
or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any
Federal contract, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or
cooperative agreement.
2. If any funds outer than Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with this 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 tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative
agreements) who receive federal fiends of $100,000.00 or more and that all subrecipients shall certify and disclose
accordingly.
4. This certification is a material representation of fact upon which reliance was placed when this transaction was
made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction
imposed by Section 1352, Title 31, U.S. Code. Any person who fails to rile the required certification shall be
subject to a civil penalty of not less than $10,000.00 and not more than $100,000.00 for each such failure.
VI. Disclosure of Lobbying Activities
Instructions
This disclosure form shall be completed by the reporting entity, whether subawardec or prime Federal recipient, at the
initiation or receipt of a covered Federal action, or a material change to a previous riling, pursuant to title 31 U.S.C.
section 1352. The filing of a form is required for each payment or agreement to snake 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 form is inadequate. Complete all items that
Contract Number 00036254, Amendmen Ngm�tr 2tl/ P � 140Y 17
apply for both the initial filing and material change report. Refer to the implementing guidance pu is le y le ice o
Management and Budget for additional information.
I. Identify the type of covered Federal action for which lobbying activity is and /or has been secured to influence the
outcome of a covered Federal action.
2. identify the status of the covered federal action.
3. Identify the appropriate classification of this report. 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 for 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 I st tier. Subawards
include but are not limited to subcontracts, subgrants and contract awards under grants.
5. If the organization tiling the report in Item 4 checks "Subawardee ", then enter the full name, address, city, state and
zip code of the prime Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level
below agency name, if known. For example, Department of Transportation, United States 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 I (e.g.,
Request for Proposal (RFP) number, Invitation for Bid (11713) 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- DE -90- 001."
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 S.
10. (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 (lie 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 (MI).
it. Enter the amount of compensation 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 (actual) 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
made.
12. Check the appropriate boxes. Check all boxes that apply. If payment is made through an in -kind contribution, specify
the nature and value of the in -kind payment.
13. Check the appropriate boxes. Check all boxes that apply. If other, specify nature.
Id. Provide a specific and detailed description of (he 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 official(s) or employee(s) contacted or the officer(s),
employee(s), or Member(s) of Congress that were contacted.
IS. Check whether or not a SF -LLL -A Continuation Sheet(s) is attached.
16. The certifying official shall sign and date the form, print his /her name, title, and teleplione number.
Disclosure offk. 11YA- ihe(tOW36254, Amendment Number 2 / Page 15 of 17
(Approved by OMB 0348 -0046)
Complete this form to disclose lobbying activities pursuant to 31 U.S.G. 1352
1 Type of Federal Action*
2 Status of Federal Action,
3. Report Type:
❑ a. contract
❑ a Bid /offer /application
❑ a, initial filing
❑ b. grant
❑ b. Initial Award
❑ b. material change
❑ c cooperative agreement
❑ c Post -Award
❑ d. loan
For Material Change Only:
❑ e. loan guarantee
❑ f. loan insurance
Year Quarter
Date of Last Report:
4. Name and Address of Reporting Entity.
5 If Reporting Entity in No. 4 is Subawardee, Enter Name
❑ Prime
and Address of Prime:
❑ Subawardee Tier (it known)
Congressional District if known
Congressional District if known
6. Federal Depart menl/Agency
7. Federal Program Name /Description:
CFDA Number (if applicable)
8. Federal Action Number (if known)
9. Award Amount (if known) :
S
10. a. Name and Address of Lobbying Registrant
b. Individuals Performing Services (including address if
(if individual, last name, first name, Nf! :
different fmm No. 10a.) (last name, first name, Mt):
(attach Continuation Sheet(s) SF- LLL -A, if necessary)
(attach Continuation Sheet(s) SF•LLL -A, if necessary)
11. Amount of Payment (check all that apply):
13. Type of Payment (check all that apply):
$ actual planned
❑ a. retainer
❑ b. one-time fee
❑ c. commission
12. Form of Payment (check all that apply):
❑ d. contingent fee
❑ a. cash
❑ e. deferred
❑ b. In -kind; specify: Nature
❑ f. other; specify:
Value
14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or
Member(s) contacted, for Payment Indicated in Item 11(attach Continuation Sheet(s) SF- LLL -A, if necessary):
15. Continuation Sheel(s) SF -LLL -A attached: ❑ Yes ❑ No
16. Information requested through this form is authorized by
Signature:
title 31 U. S. C. section 1352, This disclosure of lobbying
activities is a material representation of fact upon which
reliance was placed by the tier above when this transaction
Print Name:
was made or entered into. This disclosure is required
pursuant to 31 U. S. C. 1352. This information will be
Title:
reported to the Congress semi - annually and will be
available for public inspection. Any person who fails to file
Telephone No: Date:
the required disclosure shall be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each
such failure.
[Federal Use Only
Authorized for Local Reproduction
Standard Form - LLL
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State CCMVRQWRW&r 00036254, Amendment Number 2 / Page 16 of 17
Contractor Certifications Required by North Carolina Law
Instructions: The person who signs this document should read the test of the statutes and Executive Order listed below and consult
with counsel and other knowledgeable persons before signing. The text of each North Carolina General Statutes and of the Executive
Order can be found online at:
• Article 2 of Chapter 64: lntp•� tvww.nega.state.nc.u,, r. nactedLegislation'StututcslPDl' 13yArticleiChapter _64/Anicle_2.pdf
• G.S. 133 -32: hnp: N «ww.ncga.state.ne.us'g;ucripts' statutes /statutcloakup.pl'Istatutu 133 -32
• Executive Order No. 24 (Perdue, Gov., Oct. 1, 2009): http:: .'wnw.cthicsconunission.ne,gov/ library/pol'sll,uws /i 024.pd1
• G.S. 105- 164.8(b): liltp:!/ w%tw'.ncga.state.nc.us /Cnuciedl e gislation /Slatules/I'DI -'/BySect ion ,Chapter_105 /GS_105.16.1.8.pdf
• G.S. 143 -48.5: hap:% hctvw. ncgastate. nc. uslGnactcdLegislution.' StatuteslllTML /l3ySection!Chapter 143/GS143.48.3.111ml
• G.S. 143 -59.1: http: /Avww.ncga. state .ne.u..'1- nactedLegislat ion % Statutes /l'Dl' /ByScction!Chapter 143/GS 143- 59.I.pdf
• G.S. 143 -59.2: http:// www. ncga. state.ne.us41?nactedLegislation " Statutes /PDI)P /BySection /Chapter_ tai /GS 143- 59.2.pdr
•
G.S. 143-133.3: http:/ iwwv v. ncga .state.nc.uA- nucteJLrgislation: Statutes'1 rrNl L/ l3ySection JChupter_143iGS_143- 133.3.html
• G.S. 143B- 139.6C: htip: //%v►»v.ncga. state. ne. us /Enactedt.egislalion/ Statutes/ l' DI"/ IlySLeliutdCllaptcr ..143B/CjS_143B- i39.6C.pdt*
(1)
(2)
(3)
Certifications
Pursuant to G.S. 133 -32 and Executive Order No. 24
(Perdue, Gov., Oct. 1, 2009), the undersigned hereby
certifies that the Contractor named below is in
compliance with, and has not violated, the provisions of
either said statute or Executive Order. (4) p
Pursuant to G.S. 143 -48.5 and G.S. 143- 133.3, the
undersigned hereby certifies that the Contractor named
below, and the Contractor's subcontractors, complies
with the requirements of Article 2 of Chapter 64 of the
NC General Statutes, including the requirement for
each employer with more than 25 employees in North
Carolina to verify the work authorization of its
employees through the federal E- Verify system." E-
Vcrifv Systcm Link: wzv ,Nv.uscis.gov
Pursuant to G.S. 143- 59.1(b), the undersigned hereby
certifies that the Contractor named below is not an
"ineligible Contractor" as set forth in G.S. 143- 59.1(a)
because:
(a) Neither the Contractor nor any of its affiliates has
refused to collect the use tax levied under Article 5
of Chapter 105 of the General Statutes on its sales
delivered to North Carolina when the sales met
one or more of the conditions of G.S. 105 -
164.8(b); and
(b) [check one of the following boxes]
® Neither the Contractor nor any of its affiliates
has incorporated or reincorporated in a "tax
haven country" as set forth in G.S. 143 -
59.1(c)(2) after December 31, 2001; or
❑ The Contractor or one of its affiliates has
incorporated or reincorporated in a "tax haven
country" as set forth in G.S. 143- 59.1(c)(2)
(5)
(6)
after December 31, 2001 but the United States
is not the principal market for tite public trading
of the stock of the corporation incorporated in
the tax haven country.
irsuant to G.S. 143- 59.2(b), the undersigned hereby
certifies that none of the Contractor's officers,
directors, or owners (if the Contractor is an
unincorporated business entity) has been convicted of
any violation of Chapter 78A of the General Statutes or
the Securities Act of 1933 or the Securities Exchange
Act of 1934 within 10 years immediately prior to the
date of the bid solicitation.
Pursuant to G.S. 14313- 139.6C, the undersigned
hereby certifies that the Contractor will not use a
former employee, as defined by G.S. 14313-
139.6C(d)(2), of the North Carolina Department of
Health and I luman Services in the administration of a
contract with the Department in violation of G.S.
1436- 139.6C and that a violation of that statute shall
void the Agreement.
The undersigned hereby certifies further that:
(a) I le or she is a duly authorized representative of the
Contractor named below;
(b) He or she is authorized to snake, and does hereby
snake, the foregoing certifications on behalf of the
Contractor; and
(c) He or site understands that any person who
knowingly submits a false certification in response
to the requirements of G.S. 143- 59.1and -59.2
shall be guilty of a Class I felony.
contractor's Name: Orange County Department of Social Services
Contractor's
Authorized Agent: Signature Date l0 /l2 /2017
1'nntcd Name -Nancy Coston title Director
witness: Signature Date 10/12/2017
printed Nome Serena McPherson
ride Administrative Services Supervisor
Conlrmior C enilicatims Required by North Carolina Law Wev RC016) Pace I of
Iltc witness should be present Micn the Contrator's Authorind Agent 17
Contrtictor Ccniricntinns Reouircd by Nofth Carolina).mv (Rcv 8i2016) Pa,--c 3 or,