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2018-441-E Finance - Charles House Association outside agency agreement
DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB 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 Charles House Association, a not - for - profit corporation, located at 7511 Sunrise Road, Chapel Hill, NC 27514 ( "Provider "). 1.iIMy�1�1.Xy�lly 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 Charles House Association 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 $23,250. 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. c. The Provider shall be paid in four equal installments in the amount of $5,812.50. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (Charles House Association) Orange County Outside Agency Performance Agreement Revised 712018 Page 1 of 9 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB 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. (Charles House Association) Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 7118 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof, iii. Comprehensive Automobile Liability Insurance, including hired and non -owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury, bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: 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. (Charles House Association) Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 7118 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB 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 Charles House Association 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: (Charles House Association) Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 7118 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB County: Finance & Administrative Services Orange County Post Office Box 8181 Hillsborough, NC 27278 Provider: Charles House Association 7511 Sunrise Road Chapel Hill, NC 27514 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. Fo oocuSigned ay: f the Provider Cr6F281B2S5F664BB... Fo, Docu5ignedby, County Government 661nrA (' RmAc1'i" 0637994B755E477... Bonnie Hammersley, County Manager (Charles House Association) Orange County Outside Agency Performance Agreement Rev. 7118 8/16/2018 Date 8/17/2018 Date Page S of 9 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION [. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Charles House Association Applicant Organization's Physical Address: 7511 Sunrise Road Chapel Hill Applicant Organization's Mailing Address: 7511 Sunrise Road, Chapel Hill, NC 27514 Applicant Organization's Web Address: www.charleshouse.or Executive Director: Paul Klover Telephone Number: 919 -967 -7570 Tax ID Number: 58- 1582881 E -Mail: PauKcDcharleshouse.oro b) Funding Request List all FYI 8-19 Human Services (NS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2 -3 lines or less) Program Carrboro Chapel Hill - HS Orange County-HS Total - H5 Ex, Youth Afterschool Program Afterschool Program Coordinator salary and materials for youth activities and projects $10,000 $15,000 $5,000 $30,000 DAYTIME ELDERCARE PROGRAM $4000 $10,000 $25,000 $39,000 Totals $4000 $10,000 $25,000 $39,000 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: 2� 9 - Executive Director Da Signature,/// -� Board Chairperson Date AGENCY INFORMATION 1/22/2018 12:24:10 PM P a g e 2 o f 1 5 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION d) 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 ❑ a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ®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? ❑ 0 d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON - DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti - discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: U Executive Director Board Chairperson L. �--/ Date Date AGENCY INFORMATION 1/22/2018 12:24 :10 PM P a g e 3 o f 1 5 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB 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): Incorporated: 0311984; Operations began: 0611990; 27 years in operation b) Agency's Purpose /Mission (no more than a few sentences): • Enriching the lives of seniors • Supporting families caring for aging family members • Representing the community's commitment to its elders c) Types of Services the Agency Provides (bullet format): The Charles House Center for Community Eldercare includes: • Daytime Eldercare Program • Caregiver Orientation, Resources and Education —CORE Support Program • The Bradley Program in Learning & Service:. opportunities for students and interns to be introduced to careers in aging and the positive Charles House approach to working with elders • Agency Administration, Community Outreach, Management of Eldercare Homes Charles House operates the pioneering residential care settings — neighborhood eldercare homes —in the Heritage Hills and the Winmore neighborhoods, d) Agency's History with Providing These Services: Since 1990, Charles House has been a leader in developing innovative, highly respected, services for elders and their caregiving families. Charles House's Daytime Eldercare Program is exemplary in bringing together community members, caregiving families, elders, other community resources, funders and donors, to support some of the most frail elders and the most challenged families in our community. Since 2011, Charles House has pioneered neighborhood Eldercare Homes as an innovative model of residential care and end -of -life care. 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 ?) There are no major changes in the organization in the past year to report. 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: 18.75 # of FTE - Paid Part -Time Positions: 8.25 # of Volunteers: 100+ # of FTE - Vol unteers:10 g) 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 Employe-? NO If no, please explain. The application was completed, awaiting confirmation. Agency Information 1/2212018 2:17:04 PM P a g e 4 o f 1 5 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION h) Agency Budget i. Is your agency currently receiving and/or requesting other (non -Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? ffes /No) NO If yes, please list below: Include aN programs that have funding requests /awards /totals from Carrboro, Chanel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FYI 7-18 Award FYI 8-19 Request Source Ex: Affordable Rental Rehabilitation 0 $20,000 Carrboro - Affordable Housing Ex: Agency Administration $15,000 $15,000 Carrboro -- Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues • Private Donations • Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) Agency Information 1/22/2018 2:17:04 PM P a g e 5 o f 1 5 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Orange County Human Services ® Orange County Other (DO NOT Include HOME funding here) o Other Government Grants ® Triangle United Way ■ State Government 0 Federal Government (CDBGIHOMEIetc.) ■ Private Foundation Grants o Other Revenue ® Expenditures • Compensation • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes /No No Please provide a brief explanation for Surplus or Deficit, and significant changes. iv. What is your agency's fiscal year? January 1- December 31 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/22/2018 2:17:04 PM P a g e 6 o f 1 5 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION AGENCY NAME: AGENCY REVENUE Private Donations Agency Budget Operating Budget for Entire Agency CHARLES HOUSE ASSOCIATION Agency Generated Revenue (fees) Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants Other: Capital & Program Development Total Agency Revenue AGENCY EXPENSES Compensation Rent, Mortgage, Utilities, Maintenance Program, Food Service Administrative Outreach, Development Other Expenses: Depreciation Total Agency Expenses CAPITAL & PROGRAM DEVELOPMENT RESERVE OPERATING SURPLUS /(DEFICIT): FY 2018 -19 Agency Budget $ 1,000 1 $ 75,400 1 $ 14,000 1 Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Percent Change $ 45,000 $ 33,000 $ 26,500 -20% $ 1,370,000 $ 1,475,000 $ 1,510,000 2 % $ 3,500 $ 1,500 $ 3,500 133% $ - $ - $ - 0 $ 9,000 $ 7,000 $ 10,000 43% $ - $ - $ - 0 $ 20,000 $ 22,500 $ 25,000 11% $ - $ - $ - 0 $ - $ - $ - 0 $ - $ - $ - 0 $ _ $ $ - 0 $ _ $ - $ - 0 $ 6t1,000 $ 40,000.00 $ 20,000.00 $ $ 140,000 $ 295,000 $ 30,000 $ {0.90} $1,648,500 $ 1,133,000 $1,874,000 $ 1,140,004 $1,625,000 $ 1,220,000 -13% 7 %° $ 157,000 $ 156,500 $ 155,000 -1% $ 82,850 $ 89,500 $ 91,000 2 %© $ 39,500 $ 35,100 $ 33,500 -5% $ 27,500 $ 12,500 $ 16,500 32% $ 67,650 $ 70,000 $ 65,000 -7 %fl $1,507,500 $1,503,600 $1,581,000 5% $ 140,000 $ 295,000 $ 30,000 -907. $ 1,000 1 $ 75,400 1 $ 14,000 1 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Charles House: Daytime Eldercare Program Program Primary Contact and Title: Paul Klever, Executive Director Telephone Number: 919 -967 -7570 E -Mail: paul (_)charleshouse.org a) Indicate the type of Human Service Needs Priority, if program applicable: ® Priority Area #1: safety -net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges Z Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare X X Education Family Resources X X Jobs /Jobs Training Food Transportation Other: Please specify –Daytime Eldercare 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. • Orange County: Department on Aging — collaboration on various projects, including the Master Aging Plan, the Aging -in- Community series, sharing referrals for aging transitions, long -term care collaborative, contractually serve Orange County families/caregivers. • Orange County: Department of Social Services --- collaboration on contractually serving Orange County families/caregivers, as well as with Adult Protective Services and regulatory oversite done by DSS. • UNC- Chapel Hill — collaborations with many of the schools and academic departments /programs on opportunities for service learning for students /interns. • UNC Health Care — collaboration on clinical initiatives, volunteers and Charles House leadership • Duke University — collaboration with the Fuqua Business School and other departments /programs for service learning and Duke Family Support Program. • Central Carolina University — collaboration with the school of social work. • Durham Technical — collaboration with the occupational therapy assistant program • Watts School of Nursing — collaboration on service learning PROGRAM INFORMATION 1/22/2018 2:17:04 PM Page 7 of 15 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION * Chapel Hill Transit E -Z Rider— collaboration on transportation Orange County Animal Shelter — collaboration on community service projects for sheltered animals. ® Chapel Hill Library — collaboration on community service projects for children's library ® Chapel Hill Service League — collaboration on community service projects for the League's Christmas House. ® IFC's HomeStart Homeless Shelter — collaboration on community service projects, including flower arrangements for the HomeStart shelter. ® Carol Woods Retirement Community — collaboration on community outreach and service to residents. ® Carolina Meadows — collaboration through Carolina Meadows community agency funding program and service to residents. Various area assisted living and nursing care facilities — collaboration on service coordination, client referrals, etc. * Numerous in -home care agencies, home health and hospice agencies —work collaboratively with mutual client families • Various area schools— student groups, including music groups, volunteer at Charles House. o Area civic groups, churches — community outreach, church and group members often volunteer at Charles House. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town /County priority /goal? The Charles House Daytime Eldercare Program is a significant support to caregiving families in our community, families carrying the burdens of caring for aging and frail family members. The Daytime Program enriches the wellbeing of elders who participate in the program and provides significant support and respite to family caregivers. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council /Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. The Chapel Hill Human Human Service Needs Assessment identified priorities: Affordable Healthcare and in the priority of Education and Family Resources a sub - priority identified is Family supports and resources — The Charles House Daytime Eldercare Program addresses both these priority areas. Charles House is a primary support for families dealing with the challenges of caring for a frail elder family member. The Daytime Eldercare Program is an affordable care option for families and supports their caregiving. The Orange County BOCC Goal 1: Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well -being of all county residents. The Charles House Daytime Eldercare Program provides significant support to the health and wellbeing of some of the most frail citizens in our community and supports the wellbeing of their family caregivers. PROGRAM INFORMATION 1/2202018 2:17:04 PM P a g e 8 of 15 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION The Carrboro Board Priorities include: Create publicfprivate partnerships for various special programs..., Offer diversified programs reflective of citizen needs and promotes sensitivity to cultural diversity., and The Charles House Daytime Eldercare Program provides significant support to the health and wellbeing of some of the most frail citizens in our community and supports the wellbeing of their family caregivers. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The target population for Charles House services is families and individuals who are dealing with challenges of aging, including cognitive decline, dementia, Alzheimer's, Parkinson's, neuro - muscular disorders, stroke, vision and hearing loss, ambulation and balance concerns, social engagement decline, etc. gj Describe the credentials of the program manager and other key staff. (Ex. Identify ,Program Manager and credentials, describe training provided to volunteers, etc.) Staff credentials: Paul Klever, Executive Director, BSW, MHA Amanda Borer, Associate Director, MHA Chuck Fleming, Program Administrator, MSW, experience in aging services. Dean Fox, Program Director, MSW, 5 years Charles House experience. Brianna Baker, Program Director, Masters Recreation Therapy. The Program Team of Directors and Facilitators bring varying levels of experience, working as a collaborative team. Training is an ongoing process of orientation, peer instruction and in- service training. Volunteers who are part of the Program Team also receive orientation, peer instruction and will participate in in- service training. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. The Charles House Daytime Program is an ongoing service. The program operates Monday through Friday, 7;30 -5:30. i) Why is funding this program a good investment for the community? How does funding this program add value to the community? (250 words OR LESS) As stated in above, Charles House is an exceptional community resource addressing the challenging issues caregiving families face with aging family members. The resources and support services provided to these families is vital to our community being a welcoming and attractive place to live, work, and age. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. The Human Services Funding is critical to the Charles House Scholarship Fund, which allows services to be made available to families across the socio- economic spectrum, families of need and to accommodate the significant agency discounts for the Orange County Department on Aging and Dept, of Social Services. Without this funding, there would be severe reduction in the level of services available to Orange County agencies' clients and other families of need. k) What percentage of your target population is low- moderate income? Charles House does not collect verified income information from client families. However, the elders who are part of Charles House are all on a fixed retirement income. Some of PROGRAM INFORMATION 1/2212018 2:17:04 PM P a g e 9 of 15 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION the families are eligible for the financial support of the O.C. Dept. on Aging and Dept. of Social Services. Some of the families are engaged in family caregiving partially because their financial resources are insufficient to afford residential care in an assisted living facility or skilled nursing home. 1) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc. ?) Charles House conducts an annual survey of client caregivers. All client families in the year are invited to participate and provide their feedback. Response to this survey is consistently strong, with response rates over 50 %. This survey is compiled in a report for board members, staff and other interested parties. The importance of this survey is exhibited in that it is included in the outcomes measures for the Outside Agency Grants. m) Include any other pertinent information. PROGRAM INFORMATION 1/22/2018 2:17:04 PM P a g e 10 of 15 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement o) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (,2pecific, Measurable, Achievable, Relevant, and _Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly /disabled residents.) • Program Goal should explain what the program is trying to achieve /accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday- Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measurable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program Charles House Daytime Eldercare Program 1. Program Activity Name Family Caregiver Support: The Charles House Daytime Program supports family caregivers by offering respite from the ongoing concerns of caring for a loved one and by supporting the best functioning of their loved ones through participation in the therapeutic program Program Goal Enrollment in the program allows caregiving families to continue their care giving as they wish. Performance Measures 50% of enrolled families (projected 120) in the funding year will have the capacity to continue providing care in the home and not require, or delay, residential care placement for their participant/enrolled family member. Previous Year Program Results At the end of the 16 -17FY, 60% of the 62 families enrolled at the beginning of the FY were still engaged in caring for their loved ones. Current Year Estimated Results Estimating 65% of the 70 enrolled families at the beginning of the grant year will continue family care giving throughout the year. Next Year Projected Results Projecting 65% of the projected 77 enrolled families at the beginning of the rant year will continue family care giving throughout the year. 2. Program Activity Name Enriching the lives of elders, enhancing well -being and supporting functioning: The relationship Charles House maintains with enrolled families is the basis for the collaboration in caring. The daytime program works to support a variety of functioning abilities for participants: including self - esteem, gross and fine motor skills, social skills, verbal skills, ambulation, memory and reminiscence, activities of daily living. Program Goal The Charles House program thrives to enhance the functioning and quality of life for participants. Performance Measures Over 75% of families (projected to be 55 responding families) will report in the annual evaluation survey satisfaction with the Charles House program and will report positive effects of the program for their enrolled family members, such as improvement in their participant /enrollee's behavior, emotional status, physical and /or cognitive functioning Previous Year Program Results The 2016 Caregiver Survey showed 100% of 38 reporting families observing improvements in their family member's functioning. PROGRAM INFORMATION 2/12/2018 10:47:30 AM I -, o DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Current Year Estimated Results The 2017 Caregiver Survey showed 100% of 50 reporting families observing improvements in their family member's functioning. Next Year Projected Results It is projected that the 2018 Caregiver Survey will show over 90% of (projected 55 respondent) reporting families observing improvements in their family member's functioning. 3. Program Activity Name Maintain Program Standards: Program administration assures that all aspects of the program are in compliance with the state rules for annual certification Program Goal The program strives for a level of excellence and maintains standards required by the State Division of Aging and Adult Services Performance Measures (While the annual caregiver survey is a good tool for measuring qualitative standards of the program, state licensure is also a measurable marker.) Charles House Association will continue to surpass the NC Standards and maintain state certification tooperate as an adult day program. Previous Year Program Results Charles House received recertification by the State Division of Aging and Adult Services in July, 2016 Current Year Estimated Results Charles House received recertification by the State Division of Aging and Adult Services in June, 2017 Next Year Projected Results It is projected that Charles House will successfully complete recertification by the State Division of Aging and Adult Services in summer, 2018 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PROGRAM INFORMATION 2/12/2018 10:47:30 AM 3 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information n) Target Population Complete the following tables, with numbers (not percentages) of individuals served and to be served, to the best of your ability, Program Target Population Demographics Gender Male Female Total Ethnicity African- American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Hispanic Total Of the above, how many Hispanic /Latino Of the above, how many non - Hispanic /Latino Total Age 0 -5 years 6 -18 years 19 -50 years 51+ years Total Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown 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) Actual Estimated Projected 2016 -17 2017 -18 2018 -19 52 48 55 57 70 65 109 118 120 6 12 12 107 115 117 4 4 5 97 99 100 109 118 120 2 3 3 109 118 120 2 3 3 107 115 117 109 118 120 4 3 4 20 18 20 26 30 25 109 118 120 109 118 120 4 3 4 20 18 20 26 30 25 2 2 2 Total I 109 118 1 120 PROGRAM INFORMATION 1/22/2018 2:17:04 PM P a g e 11 of 15 40 47 50 10 10 12 1 7 7 7 Total I 109 118 1 120 PROGRAM INFORMATION 1/22/2018 2:17:04 PM P a g e 11 of 15 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION p) Program Budget 1. Submit your program 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, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: Revenues o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other ® Chapel Hill Human Services ■ Chapel Hill Other (DO NOT include CDBG funding here) ® Orange County Human Services ■ Orange County Other (DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Government (CDBGIHOMEIetc.) • Private Foundation Grants o Other Revenue Expenditures • Compensation • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses 2. Program Budget Detail -- Provide description of "other" budget items, not defined. 3. This program budget represents what percent of the agency budget? 40 % 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 1/22/2018 2:17:04 PM Page 1 4 o f 15 Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Total Cost of Program $565,000 $591,100 $629,600 Total # of Individuals 109 118 120 Cost Per Individual $5188 $5009 $5242 Total # of Service Days 7010 7700 8200 Cost Per Individual $81 $77 $77 PROGRAM INFORMATION 1/22/2018 2:17:04 PM Page 1 4 o f 15 DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: CHARLES HOUSE DAYTIME ELDERCARE PROGRAM PROGRAM REVENUE Private Donations Program Generated Revenue Local Government Grants: Human Services - Town of Carrboro Other - Town of Carrboro Human Services - Town of Chapel Hill Other - Town of Chapel Hill Human Services - Orange County Other - Orange County Other - Town of Hillsborough Other Government Grants Triangle United Way State Government Federal Government (CDBGIHOMEIetc.) Private Foundation Grants Other Revenue Total Program Revenue PROGRAM EXPENSES Compensation Rent, Utilities, Maintenance Program, Food Service Administrative Other Expenses: Depreciation Total Program Expenses SURPLUSI(DEFICIT) FOR PERIOD: 1 $ 29,000 26,900 1 $ 27,500 1 2% FY 2018 -19 Program Budget Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Percent Change $ 12,000 $ - $ - 0 $ 540,000 $ 575,000 $ 610,000 6% $ 3,500 $ 1,500 $ 3,500 133% $ _ $ _ $ _ 0 $ 9,000 $ 7,000 $ 10,000 43% $ _ $ _ $ - 0 $ 20,000 $ 22,500 $ 25,000 11% $ _ $ _ $ - 0 $ - $ - $ - 0 $ _ $ - $ _ 0 $ _ $ _ $ - D $ _ $ _ $ _ 0 $ 10,000 $ 12,000 $ 8,000.00 $ (0.33) $ _ $ _ $ - 0 $ $ 594,500 415,000 $ $ 618,000 435,500 $ $ 656,500 471,000 60 8% $ 87,000 $ 87,000 $ 89,000 20 $ 33,500 $ 39,500 $ 40,000 1% $ 7,000 $ 6,100 $ 6,000 -2% $ 23,000 $ 23,000 $ 23,000 $ 565,500 $ 591,100 $ 629,000 tO SURPLUSI(DEFICIT) FOR PERIOD: 1 $ 29,000 26,900 1 $ 27,500 1 2% FY 2018 -19 Program Budget DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB EXHIBIT "I3" Scope of Services 1,Y 2018-19 Outside Agency Performance Agreement Agency Name: CHARLES HOUSE ASSOCIATION Program Name: DAYTIME ELDERCARE PROGRAM Funding Award: $23,250 Outline how the agency will spend Orange County's landing award. Expense Description Amount Personnel Fx ease $23,250 Program Services Outline [lie critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2019. • The Daytime Eldercare Program provides therapeutic social engagernetn, care and activity for elders and respite for family caregivers. • family Caregiver Support: The Daytime Program supports family caregivers by offering respite from the ongoing concerns of caring for a loved one and by supporting the best functioning of their loved ones through participation in the therapeutic program. • Enriching the lives of elders, enhancing well-being and supporting functionin : the relationship Charles House establishes with enrolled families is the basis for the collaboration in caring. The Daytime Program works to support a variety of functioning abilities for participants— including self - esteem, gross and fine motor skills, social skills, verbal skills, ambulation, memory and reminiscence, activities of daily living. • Maintaining Program Standards: Program administration assures that all aspects of the Program are in compliance with the state rules for annual certification. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons /units served within Oran e 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 •50 %0 of enrolled families in the funding year will have the capacity to 33 of 66 families enrolled continue providing care in the home and not require, or delay, residential care in July, 2018 will continue placement for their participant /enrollee caregiving at end of gaunt period. -Over 50% of families will report in the annual evaluation survey satisfaction More than 25 of the 50 with the Charles House program and will report positive effects of the families responding to the program for their enrolled family members, such as improvement in their annual evaluation survey participant/enrolice's behavior, emotional status, physical and /or cognitive will report positive effects functioning fi-om enrollment. •Charles House Association will continue to surpass the NC Standards and State Certification occurs maintain state certification to operate as an adult day care program in June /July annually — r� DocuSigned by: r01� kt�kw Executive Director 8/16/2018 SF2816385FSG466... Certified by: O;r �'�dn> -�� Title: X tiy r1t�� Date: 3 (Provider's Signature) DocuSign Envelope ID: C5305795- 2DF5- 4A04- B090- 9F458AA520CB 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. UocuSigned 6y:: W U" Certified by: 43F2siBSS5F664BB_. (Provider's Signature) Executive Director 8/16/2018 Title: Date: (Charles House Association) Orange County Outside Agency Performance Agreement Page 9 of 9 Rev. 7118 DocuSign Envelope ID: C5305795- 2DF5- 4A04- BO90- 9F458AA520CB �1 CHARHOU -01 DMASON ,4c'c�ieu CEV IVICATE OF LIABILITY INSURANCE DATE(MMIODNYYY) 06/04/2018 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 polleies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu Of such endorsement(s), PRODUCER CONTACT NAME; Summers Thompson Lowry, Inc. 100 Europa Drive (AICD,NN , Ext): (919) 968 - 447,2 (AAIC, No) :(919) 942 -4221 Suite 571 ADDRESS: info@STLinsure.com Chapel Hill, NC 27517 -2393 �A r INSURERISi AFFORDING COVERAGE INSURED Charles House Association Paul Klever 7511 Sunrise Road Chapel Hill, NC 27514 _ INSURER_ A: Philadelphia Ins Co INSURER B: Carolina Mutual Insurance Inc. INSURER C : INSURER D: INSURER E: _ INSURER F !'nllnn A (]CC rMorlrirA rc Au IRaM=D- RF%flglr)hl Kit IMRI=P. 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. INSR ADDL SUFIR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE IN p p POLICY NUM9ER MlOD1YYY LIMITS A X COMMERCIAL GENERAL LIABILITY AUTHORIZED REPRESENTATIVE X1,,1 R 5 .�„ w 5 EACH OCCURRENCE 3 1,000,000 CLAIMS -MADE X OCCUR X PHPK1791330 05/10/2018 05/10/2019 DAMAGE TO RENTED REMISES Ea oce urcence 100000 $ 5,000 MED EXP (Any one personj PERSONAL BADVINJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER: $. 3,000,000 _ GENT GENERAL AGGREGATE $ 3,000,000. POLICY El v6of [A LOC PRODUCTS - COMPIOPAGG $ OTHER: A AUTOMOBILE LIABILITY T. Me Ea accident 1,000,000 $ BODILY INJURY Per erson) $ ANY AUTO PHPI<1791330 05/1012018 05/1012019 BODILY INJURY Per acCidepk). $ OWNED - SCHEDULED AUTOS ONLY AUTOS P accRd Y DAMAGE $ X AUTOS ONLY X NON-OWNED A x uMBRELLA LIAR X OCCUR EACH OCCURRENCE 5 1,000,000 AGGREGATE EXCESSLIA13 CLAIMS -MADE PHUB621294 0511012018 0511012019 OED I X RETENTION$ 10,000 Comp Ops $ 1,000,000 B WORKERS COMPENSATION AND AND EMPLOYERS LIABILITY ANY PROPR €ETORIPARTNERIEXECUTIVE YIN DFFIC ERfMEMBER EXCLUDED? [Mandatory in NH) N 1 A WC19056 -2017 06/25/2018 0612512019 X ST TUTE OTHER - E.L. EACH ACCIDENT- _ 500,000 E.L. DISEASE - EA EMPLOYE _5 500, 000 S E.L. DISEASE - POLICY HMIT 500,000 $ If yes, describe under DESCRIPTION OF OPERATIONS below A Molestation/Sexual PHPK1791330 05/10/2018 0511012019 Aggregate 1,000,000 A MolestationlSexuai PHPK1791330 05/1012018 05/10/2019 Occurrence 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mare space Is required) Orange County Government is listed as Additional Insured with respect General Liability ^ A err 1 - e'A41!`CI I Arin AI ACORD 25 (2016103) c0 1988 -2015 ACORO 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 Count Government g y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE X1,,1 R 5 .�„ w 5 ACORD 25 (2016103) c0 1988 -2015 ACORO CORPORATION. All rights reserved. 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