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HomeMy WebLinkAbout2018-409-E Finance - A Helping Hand outside agency agreementDocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2018, ( "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 A Helping Hand, a not - for - profit corporation, located at 1502 W. NC Hwy 54, Suite 405, Durham, NC 27707 ( "Provider "). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners. NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and A Helping Hand agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2018 to June 30, 2019. 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 A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 6500. b. All funds appropriated shall be used for purposes described in Exhibit A. 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. The Provider shall be paid in four equal installments in the amount of $1,625. 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. (A Helping Hand) Orange County Outside Agency Performance Agreement Revised 712018 Page 1 of 9 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 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. £ 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 11, April 12, and July 12 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. (A Helping Hand) Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 7118 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 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 parry at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof, iii. Comprehensive Automobile Liability Insurance, including hired and non -owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury, bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION • Worker's Compensation • Commercial General Liability • Automobile Liability • Professional Liability MINIMUM REQUIRED COVERAGE 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. (A Helping Hand) Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 7118 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 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 $ 14.25 per hour. To the extent possible, Orange County recommends that A Helping Hand 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: (A Helping Hand) Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 7118 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 County: Finance & Administrative Services Orange County Post Office Box 8181 Hillsborough, NC 27278 Provider: A Helping Hand 1502 W. NC Hwy 54, Suite 405 Durham, NC 27707 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. a. 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. 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. 18. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For anc Docu Signed by, eider .�.�.�� ash C1 E40B0BA05346D... For a ' oocu3ignedby, ounty Government �61 AA, f%MKACY' j 0637994B755E477... Bonnie Hammersley, County Manager (A Helping Hand) Orange County Outside Agency Performance Agreement Rev. 7118 8/15/2018 Date 8/16/2018 Date Page S of 9 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application 1. COVER PAGE a] Applicant Contact Information Applicant Organization's Legal Name: A Helpiny Hand Applicant Organization's Physical Address: 1502 West NC Highway 54. suite 455 Durham, NC 27707 Applicant Organization's Mailing Address: 1502 West NC Highway 54, suite 405 Durham, NC 27707 Applicant Organization's Web Address: www.ahelpinghandnc.org Executive Director: Jennifer Ashle Telephone Number:-919-403-5555 ier.ashleyaahelDine handnc org Tax ID Number: 56- 1923835 bj 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 Carrbora Chapel Qr�anr a Total - HS Pill - HS Count -HS Our Caregiving Collaboration is one part Geriatric $6,000 $6,000 $+6,500 $18500 workforce enhancement program which serves to provide vital services to low income seniors. Totals $18,51]0 c] To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: Signature: PV/8 Date Date I AGENCY INFORMATION 1/23/2018 11:44:33 AM DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application dj DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates_ YES NO ❑ E a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ Z b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ c) Current beneficiaries of the program for which funds are being requested? ❑ ❑ d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON ;DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity /expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti - discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily (make the program ineligible for funding, but the existence of an undisclosed conflict mpy result in the termination of any Arant awarded. Signature: Signature: J -� Date Date AGENCY INFORMATION 1/2312018 11:40:33 AM P 4; f DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 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 (MonthlYear): June 1995 b) Agency's Purpose /Mission (no more than a few sentences): A Helping Hand (AHH) is the only nonprofit companion care organization in Orange, Durham and Chatham Counties, Founded over 20 years ago, A Helping Hand continues to work with older adults and their families to provide essential services such as escorted medical transportation, in home assistance and advocacy. c) Types of Services the Agency Provides (bullet Format): • Service Learning Internship Program • Escorted Medical Transportation • In Home Assistance • Shopping Assistance • Medication Reminders • Companionship • Advocacy and Care Coordination d) Agency's History with Providing These Services: A Helping Hand has been working for over 20 years to improve the quality of life, decrease health disparities and reduce barriers to human services. In addition, we are an active participant in county and statewide aging initiatives as well as a trusted community partner to organizations and companies working within the aging community. 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 ?) f) Schedule of Positions (For Entire Agency) • Full Time Equivalent (FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. Calculate a Full Time Equivalent for all recorded volunteer hours using the following; Total Volunteer Hours = Volunteer FTE 2,080 # of FTE - Full -Time Paid Positions: 4 # of FTE - Paid Part -Time Positions: 1.4 # of Volunteers: 80 # of FTE - Volunteers: 227 Agency information 1/2312018 11 :40:33 AM DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application gj Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/ No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? Yes If no, please explain. A Helping Hand provides living wage salaries for our Administrative Staff. Paid companions are compensated on a scale that starts at $8.50 and increases to $13.00 based on time with the agency and background. Additionally, certain shifts depending on factors including the time of day and length, pay at higher "rates'. Companions are also reimbursed .54 per mile for transporting clients. When AHH companions are working with Orange County clients, we pay those companions the living wage rate calculated and required by Orange County. We are a progressive organization that is actively working with our own Board of Directors to increase wages within the next 5 years, We are also working with colleagues in this industry to find care models that would support such an increase in salary without passing that cost directly on to the clients, who pay for this service largely out of pocket. Agency Information 1/23/2018 11-40.33 AM P a g (-; 7 ; i DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application Agency Budget operating Budget for Entire Agency AGENCY NAME: A Helping Hand Actual Estimated Projected Percent AGENCY REVENUE 2016 -17 2017 -18 2018 -19 Change Private Donations $ 102,100 $ 102,500 $ 102,540 0% G ted Revenue (fees) $ 445,225 $ 450,000 $ 450,000 1 0©% Q Agency enera Local Government Grants: 495,000 $ 495,000 Human Services - Town of Carrboro $ 4,000 $ 5,000 Other - Town of Carrboro $ - $ - Human Services - Town of Chapel Hill $ 4,000 $ 4,000 Other - Town of Chapel Hill $ - $ - Human Services - Orange County S 4,000 $ 6,500 Other - Orange County $ - $ Other - Town of Hiltsborough $ - $ - Other Government Grants $ 80.00 $ 80.00 Triangle United Way State Government $ - $ Federal Government (CDSG /HOME /etc.) $ - $ - Private Foundation Grants $ 11,500.00 $ 11,500.00 Other Revenue Durham Co. $ 15,000 1 $ 25,000 Total Agency Revenue AGENCY EXPENSES Compensation Rent & utilities Supplies & Equipment Travel & Training Other Expenses: Total Agency Expenses SURPLUS/(DEFICIT) FOR PERIOD: FY 2018 -19 Agency Budget $ • 111 a lllllllll� :� 11 1f11! 25.0 $ 585,905 1 $ 604,58€1 S $ 608,080 20 % 0 50 % 0 0% 0 0 0 0 0.04 $ 477,258$ 495,000 $ 495,000 0 % $ 29,235 $ 29,300 $ 30,000 2% $ 9,502 $ 9,000 $ 9,000 0 % $ 1,263 $ 1,280 $ 1,280 0% $ 68,547 $ 585,905 ` $ 604,580 $ 608,080 1% DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application h) Agency Budget L is your agency currently receiving and/or requesting other (non -Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) No if yes, please list below: include all programs that have funding requestslawardsltotals from Garrboro, Chapel and Oran a Count governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. *Add rows or attacn acionionai pays, ii i iv--- 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). iii. Does your agency budget show a Surplus or Deficit? Neither Is there a significant change? Yes/No No iv. What is your agency's fiscal year? July 1 through June 30 Agency Information 1/2312018 11:40:33 AM P 3 cj , 1 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application 3. PROGRAM INFORMATION (submit a separate Section 3 for each Program Name: Care ivin Collaborative Program Primary Contact and Title: Jennifer Ashley, y Executive Director Telephone Number: 919 -493 -5555 ram E -Mail: Jennifer .ashiey@ahelpinghandnc.oro a) Indicate the type of Human Service Needs Priority, if program applicable: M 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 bj 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 Affordable Housing Neighborhoods/Residents Affordable Healthcare Education X Family Resources Jobs /Jobs Training X Food X X Trans ortation X X X Other: Please specify X Access to healthcare X X 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. Community collaborations and partnerships are instrumental to meeting the needs of our community's seniors. A Helping Hand is actively engaged in collaborative efforts to make Orange County the premier place to grow older and participates in a number of partnerships, committees and initiatives, including: • Orange County Department on Aging: In addition to having a companion care contract with OCDOA, A Helping Hand collaborates on mutual clients. Additionally, AHH participates in many initiatives and programs sponsored by OCDOA, including their Music in my Mind program and The Sharp Caregiver Awards. • Charles House: AHH places interns at Charles House each semester to provide them with an understanding of dementia and the value of day center settings. • Chatham - Orange Community Resource Connections for Aging and Disabilities Committee: C/OCRC is attended by AHH staff for resources and c 11 b PROGRAM INFORMATION o a oration. 1123/2018 11:40 :33 AM page DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application AHH regularly refers clients to, and receives referrals from: • The Orange County 'Department on Aging • Orange County Department of Social Services • Orange County Health Department • UNC Hospitals • Veteran's Administration • Meals on Wheels • Local physicians, social workers, and clinics d) Summarize the program services proposed and how the program will address a Town /County priority /goal? A Helping Hand has created an innovative approach to address the increased demand for vital services by low income seniors. By utilizing the naturally occurring resource of UNC and Duke pre - health students we have formed a Caregiving Collaborative that serves two vital purposes: 1) Provide non - medical independent living services for senior citizens and adults with disabilities, regardless of their ability to pay. Services include escorted medical transportation, in -home assistance including light housekeeping and meal preparation, companionship, and respite care. These services are provided by pre health interns required to provide 10 hours per week of scheduled service to low income older adults. 2) An internship program focused on preparing future practitioners for an increase in the national geriatric population. A primary goal of this program is to provide exposure and meaningful interaction that will result in these future professionals viewing older adults as people and not just patients. Additionally, students who participate in this program develop a more intimate connection to their community. Volunteer based senior programs have historically struggled with the schedules and availability of said volunteers. The primary need for older adults is transportation to medical appointments and grocery shopping. The hours most needed for assistance are business hours and days (Monday through Friday, 8am to 5pm). By utilizing a corps of student interns to create the foundation of our Caregiving Collaborative, we have eliminated this primary road block as students have weekly schedules vastly more flexible than most volunteers. In addition, students are invested in completing this program based of the requirements they must meet for medical school applications. In all 3 town /county plans, transportation was listed as a priority. This Collaborative includes a sustainable transportation model that eliminates barriers of traditional cost and availability issues. Orange County highlighted the goal of enabling full civic participation, which this program addresses as well. With this program AHH is not only driving the civic engagement of college students but allowing the older adults we serve to engage more fully in their own communities. As Kathy Bonner, a retired principal and AHH Companion has stated, "For the people we serve, their worlds are shrinking. We are there to expand their worlds again." PROGRAM INFORMATION 1/23/2018 11:40:33 AM P a g e 1 3 o f 2 1 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application ej Describe the community need or problem to be addressed in relation to the Cha el Hill Human Services Needs Assessment, Orange Countv 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. As the population of seniors (65 +) increases exponentially, an expansion of services is required to meet the special needs of this at -risk demographic. In 2013, one in 5 North Carolina residents were 60 and over in the state. In 2033, one in four will be over 60 and over. According to the US Census Bureau, there are approximately 13,962 individuals aged 65+ in Orange County; nearly 10 %a of these individuals are living at or below poverty level and are unable to afford independent living services. This augmented population of seniors is resulting in an increased demand for services on an already heavily burdened human services system. In order to reduce the public cost of caring for these individuals, it is necessary to provide services that allow a person to "age in place" with minimal barriers to service. A Helping Hand (AHH) is the only non - profit in Orange County that provides in -home assistance regardless of an individual's ability to pay. Transportation is frequently identified as the number one unmet need for seniors. In fact, the latest Orange County Health Assessment identified the lack of transportation services as a primary barrier to healthcare access. Fortunately, AHH is able to increase access to healthcare and other valuable services by filling gaps in current transportation models. As current community transportation exists, assistance is limited to "door -to- door" and is subject to geographical and scheduling restrictions. AHH's escorted "door - through - door" transportation is critical to ensuring physically - disabled or cognitively- impaired seniors are able to travel safely to doctor's appointments and have access to other vital needs, regardless of time and location in the County. Moreover, the discrepancy between life expectancy and driving expectancy creates a pragmatic need for senior transportation services. On average, men and women experience respectively, seven and ten non - driving years. Ironically, as the ability to drive decreases, the frequency of medical appointments and the need for health services increases. The natural aging process often brings about physical and cognitive limitations that require assistance in the home. The OHHS Administration on Aging reports 37 %4 of older people are limited by a disability. Moreover, in the future, the percentage of disabled individuals is also expected to grow. A report published in JAMA Internal Medicine, showed that the proportion of baby boomers who are disabled is substantially higher relative to people from two decades ago in the same age bracket. Without assistance, these individuals will experience premature transitions to higher, more expensive levels of care and are at increased risk for injury and illness. Providing independent living services will enable these individuals to maintain self - sufficient lives and will reduce the likelihood of injury from performing unmanageable household tasks. Social isolation among the elderly is a silent and often overlooked pandemic threatening the health and quality of life of our community's older adults. According to the American Community Survey, over 3,300 Orange County seniors over age 65 live alone. Many of these individuals are geographically isolated from their families and lack necessary support networks. A report in the Archives of Internal Medicine found 43 % of older adults reported feelings of loneliness which can lead to depression, other negative psychological impacts, loss of physical functioning, and even premature death. Lonely adults in the study were 45% more likely to die than seniors who felt meaningful connections with others. AHH's companionship services provide an increased opportunity for socialization and mental stimulation. PROGRAM INFORMATION 1/2312018 11:40 :33 AM 4 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application As reported in the Recommendations from the Governor's Advisory Council on Aging, failure to sustain, if not increase, funding for senior services could have serious adverse effects on the well -being of the elderly and the public cost of caring for them. Funding from the Town of Chapel Hill, the Town of Carrboro and Orange County is essential to ensuring A Helping Hand is able to respond to the growing needs of Orange County senior citizens. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? Low income seniors (60 +) and adults with disabilities residing in Orange County. Though not our target population of individual we are serving, we also posit that our internship participants, namely Duke and UNC pre health students, will benefit greatly from this experience which will in turn effect the communities in which they reside and work. A Helping Hand, having been in operation for 20 years and with a reputation for high quality care and community involvement, solicits referrals from its community partners. These include UNC hospital system, Piedmont Health, Charles House, Orange County Department on Aging, and many others. Not to be underestimated, AHH also has a robust 'word of mouth' presence in the community.. Once identified, AHH provides an in -home assessment of each person. In this assessment we ask potential clients to complete a short financial affidavit and calculate client eligibility based on considerations such as: income, assets, debt, medical expenses, etc. AHH also evaluates whether the level of service we provided, companion care, is appropriate for the individual's needs. if not, we make sure to provide a coordinated referral to a higher level of care. We are also assessing for the safety of the individual in their home as well as the safety of a potential companion. Finally, AHH is collecting vital information regarding the person and their needs in order to match them with a companion who will not only be able to provide them with assistance but also someone they can connect with on an individual level. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Jennifer Ashley, Executive Director, received her BA in Cultural Studies from University of Florida and MPA from City University of New York, Baruch College. She has over 15 years of nonprofit management experience and has spent the majority of her career focusing on the senior population. Steffi Tornow, Volunteer & internship Coordinator, received her BA in Urban Studies from College of Charleston. She is an Americorps and NCCC alumni and has worked with AHH for many years in various capacities, including as a volunteer companion. Each intern is interviewed and undergoes a background and DMV record check. They are also run through the North Carolina DHSR registry and required to provide 3 references. Once approved, interns attend a full day training through AHH before working with clients. This training includes an overview of our Companion Handbook, which explains internal policies & procedures, DHSR regulations and provides `tips' for companion care work. Interns are instructed on and provided with materials related to proper boundaries, effective communication, companion safety, age related issues and mobility. PROGRAM INFORMATION 1/23/2018 11:40:33 AM P a ti e 1 5 o i 2 1 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application In addition, interns participate in the Secure Project sensitivity training. AHH provides various guest speakers on this day as well, including topic lectures from Therapeutic Alternatives, practicing Occupational Therapists, the Director of UNC Partnership in Aging program, members of our Board of Directors, clients and former interns. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. A Helping Hand provides the Caregiver Collaborative program throughout the year and has utilized the support of the internship program in this manner for more than 10 years. Our recruitment and onboarding of interns occurs within the first month of each semester. 0 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) The Caregiver Collaborative continues and expands Orange County's commitment to improving the quality of long term senior care options. It contributes to eliminating barriers to essential services and provides the somewhat transient student population in this area with a more personal connection to the community. Furthermore, an investment in this program is an investment in the future healthcare practitioners of this and other communities. We are creating and improving upon the roadmap to elderhood that we will be using in our own aging process. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. A Helping Hand is at a turning point in its development and is working to expand its capacity over the next 3 to 5 years. Without the requested funding, AHH will not be able to make the vital leap forward that is required to meet the increasing demand for these services. We have recently begun to track all assignment requests that we are unable to fill, which are primarily for transportation to medical appointments. In doing this, we discovered that an average of go assignments per month go unfilled due to lack of capacity_ Approximately half of those requests are from Orange county residents. k) What percentage of your target population is low- moderate income? 100% of our target population are low to moderate income. 1) What efforts do you make to seek feedback about your program from your target population? This year we will be conducting a satisfaction survey of all those in our target population which will include ample space for suggestions for additional services and improvements. m) Include any other pertinent information. We are currently working on an online training module to provide interns and volunteers with a wider array of topics to train on during their time with us. These include: death & dying, client rights, addressing challenging behaviors and professional boundaries. PROGRAM INFORMATION 1/2312018 11:40:33 AM P � g � 1 6 0 f 2, DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application Additional Pro ram Information nj Target Population Gender Ethnicity Age Program Target Population Demographics Actual Estimated Projected 2016 -17 1 2017 -18 2018 -19 Male Female Total 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 0 -5 years 6 -18 years 19 -50 years 51 + years Total Geographic Location Alamance County Chatham County Durham County Wake County 7270 20 75 221 225 250 293 295 325 Aran a County Breakdown V 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) 3 20 20 290 275 305 293 295 325 30 35 40 10 8 8 108 115 125 2 2 2 30 35 40 92 90 100 33 35 40 12 10 10 Total 1 293 295 325 PROGRAM INFORMATION 1/2312013 11:40:33 AM P g­ 17 of 21 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application Work Statement Chart for Program Caregivinp Collaborative 1. Program Activity Name Volunteer Companion Care Program Goal Provide companionship, escorted medical transportation, in home assistance, meal preparation and respite care to a minimum of 160 Orange County low income seniors. Performance Measures We will track the number of scheduled visits along with tasks erformed in each visit. Previous Year Program Results Over 150 clients were provided these companion care services. Current Year Estimated Results 160 or more clients will be provided these companion care services. Next Year Projected Results 180 clients will be provided these companion care services. 2. Program Activity Name Pre Health Internship Program Goal Train and assign 40 pre health interns to Orange Count7future need of companion services, with the goal of enhanpractitioner's understanding of the realities of aging in . Additionally, working to connect these interns to the greater community and impact their long term views on aging and service. Performance Measures We will be conducting a pre and post test to gauge the understanding and empathy levels of participating interns. Previous Year Program Results 35 pre health interns participated in this program last year. Current Year Estimated Results 40 pre health interns will participate in this program. Next Year Projected Results 40 pre health interns will participate in this program. 3. Program Activity Name Programs Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PROGRAM INFORMATION 1/23/2018 11:40:33 AM Page B of" 21 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application o) Program Budget 1. Submit your program budget. (use template) 2. Program Budget Detail — Provide description of "other" budget items, not defined. a. Insurance: Workers Comp, General liability, Board Liability b. Background Checks c. Intern Mileage :.14 per mile d. Advertising for interns and volunteers e. Marketing /Printing f. Technology g. Volunteer /Intern Recognition: end of semester client celebration, annual volunteer/intern recognition event 3. This program budget represents what percent of the agency budget? 3% 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 1/23/2018 11:40:33 AM Page 1 9 of 21 Actual 2016 -17 Estimated 2017 -18 Projected 2018-19 Total Cost of Program /Outside 14,000 15,000 16,000 Agency Total # of lndividuals 293 295 325 Cost Per Individual 47.78 50.8 49.23 PROGRAM INFORMATION 1/23/2018 11:40:33 AM Page 1 9 of 21 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 Exhibit A: Provider's Outside Agency Application Program Budget Operating Budget for Program PROGRAM NAME Caregiwing Collaborative Actual Estimated Projected Percent PROGRAM REVENUE 2016 -17 2017 -18 2018 -19 Chan e Private Donations $ 102,100 $ 102,500 $ 102,500 0% $ _ .S - $ - 0 Program Generated Revenue $ 85,000 Local Government Grants: 85,000 0% Human Services - Town of Carrboro S 4,000 Other - Town of Carrboro $ - Human Services - Town of Chapel Hill S 4,000 Other - Town of Chapel Hill $ - Human Services - Orange County $ 4,000 Other - Orange County $ - Other - Town of Hillsborough $ - Other Government Grants 60,080 5% Triangle United Way $ 80.00 State Government $ - Federal Government (CDBGIHOMEletc.) $ - Private Foundation Grants $ 11 500.00 Other Revenue $ 15.0{10 Total Program Revenue PROGRAM EXPENSES Compensation Rent & Utilities Supplies & Equipment Travel & Training Other Expenses: Total Program Expenses SURPLUS/(DEFICIT) FOR PERIOD: FY 2018 -19 Program Budget gut 80.00 15,000.00 25 . Irr li ►r� rr Fri 0 20% 0 50% 0 $ 140,680 1 $ 158,084 1 $ 161,080 , 2 %. $ 75,500 $ 85,000 $ 85,000 0% $ 10,000 $ 10,000 $ 10,000 0% $ 4Y50 $ 5,500 $ 5,500 0% $ 500 $ 500 $ 500 0% $ 49,930 $ - 57,080 $ 60,080 5% $ 140,680 1 $ 158,0801 $ 161,080 j 2% DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 151:4: I 1111"Iu Scope of Services — FY 2018 -19 Outside Agency Performance Agreement Agency Name: A Helping Hand Program Name: Caregiving Collaborative Funding Award: $6,500 Outline how the agency will spend Orange County's funding award. Expense Description Amount Wages and FIC costs for program facilitators $4,250 Intertiship Program costs: training materials, mileage, advertising and office material costs $2,250 Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2019. • Provide companion services to low income seniors, including: escorted medical transportation, shopping assistance, and in -home help. • Recruit, train and provide interns with an intergenerational service experience. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons /units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Recruitment, onboarding and training of 40 health interns. 1 40 1 Provide 180 clients with scheduled visits for escorted medical transportation, shopping assistance 180 and in -home help. DocuSigned by: QS Executive Director 8/15/2018 clEaaeaoaog3 Certified by: 46D _ Title: Date: (Provider's Signature) DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 ATTACHMENT "A" Orange County Certifications — FY 2018 -19 Outside Agency Performance Agreement Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title, residential address; phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing, with the name, physical address, mailing address and if possible, phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. DOCUSigned by: Certified by: _ C1EaoBfl�AO5346o... (Provider's Signature) Title: Executive Director Date: 8/15/2018 (A Helping Hand) Orange County Outside Agency Performance Agreement Page 9 of 9 Rev. 7118 DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 A►C[7►2D" OP ID: ILK �-�- CERTIFICATE OF LIABILITY INSURANCE DATE 05rzs/201IMM 201 YYI $ 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(les) must be endorsed. If SUBROGATION IS WAIVED, subjec�the the terms and Conditions of the Policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to certificate holder in lieu of such endorsements . PRODUCER C CONTACT 6015 Farrington Rd. Ste 101 w we No eat }; 919 -913 -1144 i FAX NO). 919 -513 -1155 Chapel Hill, NC 27517 E E -MAIL ADORES& (aura hi handrubish.eom PRODUCER T HELPi -1 CUSC?NIER IO p: INSURED A Helping Hand I INSta !ERISIAFFORDIHG COVERAGE H HAIL A 1502 W Hwy 54 Ste 405 I INSURER A: Cincinnati Insuranr-a Corn antes 7 710577 Durham, NC 27707 I INSURER e ; U.S. Linhilli Insurance Co. 2 25895 INSURER C; - - INSURER D : INSURER E: COVERAGES I INtsDRER F THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE L REVISION NUME3ER• LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED R OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W WHICH THIS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY H DESCRIBED HEREIN IS SUBJECT TO ALL T THE TERMS, LTR TYPE OF INSURANCE ~ + Pt7LFCY EFF P NS; I I POLICY E](T A COMMERCIAL GENERAL LWBILITY IiHC0005$$8 E EACH OGCURRENCE $ 1 1,000,0 CLAIMS -MADE OCCUR PREMISES Eaoccurrr e $ 1 1 ®0,0 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 141, Additional Remarks Schedule, it more space IsIrequired) CERTIFICATE HOLDER CANCELLATION 6RANG -3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Government THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 S. Cameron St ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Boat 8181 Hillsborough, NC 27278 -8181 AUTHORIZED REPRESENTATIVE ACORD 25 (2009109] C 1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: 6818677A -D518- 4750- B391- F6169FB2A4C4 AHELP -1 rte- DATE (AtlId+DDrYYYY) CERTIFICATE �F LIABILITY INSURANCE 07/10/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL. INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 773- 754-0849 CONTACT S. Wolf and Associates, Inc, NAME 2338 W. Morse [AfC, Rio, Extl: 773-754 -0849 Chicago, IL 60645 E -MAIL Polly Kosyla88E - - - - -- --�_ INSORER(S) AFFORDING COVERAGE NA1C # ............ ____.__ IHSURERA:WesCo Insurance Company INSURED A Helping Hand NC _ INSURER B -_ ......... Jon niferAshley 1502 W NC Hwy 54 -#405 LX§42ERC: _ Durham, NC 27707 1 -11... n. INSURER F: rnVFRAr.FC f'COTICIr ATC KIIIl1Aa CO• QCVIC VIN LI II ILA 12=12- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - TYPE OF INSURANCE off- UDR ppDCY NUMBER POLICY EFF POLICY EXP LIMITS - - - iLT R - PO box 8181 COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR Hillsborough, NC 27218 I AUT"CR11ED REPRESENTATWE " 6116144-- �'f�'� 61 EACH OCCURRENCE DAMAGE TO RENTED MED EXP (Any one person) S PERSONAL 8 ADV INJURY i— GEN'L GENERAL AGGREGATE ,- ._- .-- ._..._— __..._ S AGGREGATE LIMIT APPLIES PER: POLICY L _J J FI LOC PRODUCTS - COMP/OPAGG - -. -- OTHER' AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY JPer rson BODILY INJURY Per accident S __. AUTOS ONLY AUTO V6' L6 PROPERTY _ r_anc t MADE c c UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS -MADE AGGREGATE. S DED I i RETENTION $ A WORKERS COMPENSATION X PER OTH- STATUTE rR AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERfEXECUTIVE YID FICE Mgg EXCLUDED? L� landaM laryn NHy �� R yes, describe under DESCRIPTION OF OPERATIONS below N 1A WWC3356988 0713412018 07130/2019 E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYE 1,000,000 --' --"" E.L. DISEASE - POLICY LIMIT ... . 1'4QQ' ©QQ I I DESCRIPTION OF OPERATIONS I LOCATIONS! VEHICLES (ACORD 101, AddI ional Remarks Schedule, may be attached if more space is required) rF:PTIFIr ATF 1-Ir11 nFR f AA1!'CI I ATInm ACORD 25 (2016103) ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and Logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange County Government THE ACCORDANCE WFTHTHE POUCYRPROVISIONSE WILL BE DELIVERED IN 200 South Cameron Street PO box 8181 Hillsborough, NC 27218 I AUT"CR11ED REPRESENTATWE " 6116144-- �'f�'� 61 ACORD 25 (2016103) ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and Logo are registered marks of ACORD