HomeMy WebLinkAbout2018-445-E Finance - KidScope outside agency agreementDocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E7BD
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 KidSCope: Chapel Hill Training Outreach Project,
Inc., a not - for - profit corporation, located at 800 Eastowne Dr., Suite 105, Chapel Hill, NC 27514
( "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 KidSCope: Chapel Hill Training Outreach Project, Inc. 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 $75,000.
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 $18,750. 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.
(KidSCope: Chapel Hill Training Outreach Project, Inc.)
Orange County Outside Agency Performance Agreement
Revised 712018 Page 1 of 9
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E7BD
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.
e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21
days after receipt of the Progress Report and Request for Reimbursement or 21 days after
due date of Progress Report whichever is later.
f. The County is not obligated to provide any other support to Provider in this or in
succeeding fiscal years.
4. Agency Reporting.
a. Provider will provide Orange County a Progress Report that includes a fiscal report and
updates on performance measures as outlined in the Scope of Services. Progress Report
dates are: July 1 — December 31; January 1 — March 31 and April 1 - June 30. Reports are
due on January 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
(KidSCope: Chapel Hill Training Outreach Project, Inc.)
Orange County Outside Agency Performance Agreement Page 2 of 9
Rev. 7118
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E7BD
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.
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 MINIMUM REQUIRED COVERAGE
• Worker's Compensation
• Commercial General
Liability
• Automobile Liability
• Professional Liability
Limits for Coverage A - Statutory State
NC & Coverage B - Employers Liability
$500,000 each accident, disease policy limit and
disease each employee
$1,000,000 Each Occurrence
$2,000,000 Aggregate
$500,000 Combined Single Limit
$1,000,000 Each Occurrence
$2,000,000 Aggregate
c. All insurance policies (with the exception of Worker's Compensation and Professional
Liability) required under this Agreement shall name the County as an additional insured
party and as a certificate holder. Evidence of such insurance and all correspondence shall
be sent to:
Orange County Risk Manager
Post Office Box 8181
Hillsborough, NC 27278
(KidSCope: Chapel Hill Training Outreach Project, Inc.)
Orange County Outside Agency Performance Agreement Page 3 of 9
Rev. 7118
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E7BD
d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity
defenses.
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 KidSCope: Chapel Hill Training
Outreach Project, Inc. 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
(KidSCope: Chapel Hill Training Outreach Project, Inc.)
Orange County Outside Agency Performance Agreement Page 4 of 9
Rev. 7118
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E7BD
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:
County: Finance & Administrative Services
Orange County
Post Office Box 8181
Hillsborough, NC 27278
Provider: KidSCope: Chapel Hill Training
Outreach Project, Inc.
800 Eastowne Dr., Suite 105
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 I IA and Article 40 of North Carolina General Statute Chapter 66.
IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on
the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures
below.
F D 'S- 9neAy:' — )f the Provider
4F69�983C41148C...
F, Doeusignedby, _ - e County Government
0637994B755E477...
Bonnie Hammersley, County Manager
(KidSCope: Chapel Hill Training Outreach Project, Inc.)
Orange County Outside Agency Performance Agreement
Rev. 7118
8/16/2018
Date
8/20/2018
Date
Page S of 9
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E713D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
1. COVER PAGE
a) Applicant Contact Information
Applicant Organization's. Legal Name: Chapel Hill Training Outreach Proiect, Inc.
Applicant Organization's Physical Address: 800 Eastowne Drive, Suite 105
Applicant Organization's Mailing Address: 800 Eastowne Drive, Suite 105
Applicant Organization's Wed Address: www.chtop,org
Executive Director: Mike Mathers
Telephone Number: 919 490 5577
Tax ID Number. 58- 204352
E -Mail: mmathers@chtop.ora
b) Funding Request
List all FY18 -19 Human Services (HS) Funding Being Requested -
For All Programs) and the Proposed Use of Funds (2 -3 lines or less)
Program
Carrtboro
Chaoet
Hill - HS
Orance
County-HS
Total
- HS
Ex. Youth Afterschool Program
Afterschool Program Coordinator salary and materials
for youth activities and projects
$10,000
$15,000
$5,400
$30,000
KidSCope Outreach: Early Childhood Mental Health
therapist salary and program expenses
$3,400
$6,000
$75,000
$84,000
Totals
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.
�2Signature., L
Executive Director
Signature: :r V� -� -�.� L_ '�.,Q�L �
Board Chairperson
1 bb
Da e
(late
I /r i I A V_
AGENCY INFORMATION 1/9/2018 2:45:48 PM Page 7 of 2'
d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION
CLAUSE
AGENCY INFORMATION 1/22/2018 3:23:54 PM
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E713D
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
❑ ® 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 bill, or Orange County?
Z 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 may result in the termination of any grant awarded.
Signature:
Executive Director
Iii "^- - C_�• fit- �� -'
Signature: _
Board Chairperson
L' E'' x
Dat
Date
l /'l i /t<�
AGENCY INFORMATION 1 /9/2018 2:46:51 PM Page 8 of 23
AGENCY INFORMATION 1/22/2018 3:23:54 PM Page 10 of 27
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
2. AGENCY INFORMATION (Be Very Brief and Concise)
Please provide the following information about your agency (2 pages OR LESS):
a) Years in Operation, Date of Incorporation (Month/Year): 4/6/1988
b) Agency's Purpose /Mission (no more than a few sentences):
The mission of KidSCope is to provide comprehensive early childhood
developmental /mental health support to young children, their families, and care
providers. Through the use of research and specialized evidence based services,
KidSCope aims to give children a healthy start in the early years, when relationships
and experiences influence future life success the most.
c) Types of Services the Agency Provides (bullet format):
KidSCope provides:
• inclusive child care
• social - emotional health services using evidence -based modalities, including Parent
Child Interactive Therapy and Child Parent Psychotherapy,
• child care mental health consultation and teacher education
• parent education - Incredible Years Basic /Incredible Babies /Toddlers.
• a myriad of childhood development and parenting resources
• support to medical practices to assess children for developmental /mental health at
well child visits and to provide information and referral to local programs and
resources.
d) Agency's History with Providing These Services:
KidSCope was created in 1988 under OPC Mental Health Center, by a coalition of
professionals and child advocates, to address a documented need for specialized
services to young children who are experiencing social, emotional, and /or behavioral
difficulties. KidSCope was divested under state mental health reform to a local non-
profit, Chapel Hill Training Outreach Project, Inc. on October 1, 2005.
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 ?)
Unfortunately, KidSCope was not able to secure a new Hillsborough location after
Orange County Schools did not renew our lease at Hillsborough Elementary.
KidSCope provided quality child care to children with and without special needs, as
well as mental health therapy and parent education from that site for 23 years.
Although those services are still available from KidSCope county wide, proving
services has become much more complicated due to distance and location.
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
Agency Information 1/22/2018 3:23:54 PM R a g e 11 of 2
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 9441D2300EM
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
# of FTE - Full -Time Paid Positions: 21
# of FTE - Paid Part -Time Positions: 7
# of Volunteers: 10 # of FTE - Volunteers:.05
g) Living Wage
Does this agency pay permanent employees a minimum living wage? (Yes /No) No
If yes, is this agency an Orange County Living Wage Certified Employer?
If no, please explain.
Paying our employees a "living wage" is a goal for the KidSCope program that we are
very close to achieving. KidSCope is, however, a program of Chapel Hill Training
Outreach Project, Inc., a non - profit with many employees. Although the goal of paying
a minimum living wage is an admirable one, KidSCope is not involved in salary decisions
for the entire agency.
Agency Information 1/22/2018 3:23:54 PM q c-, I 2� s t
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
Agency Budget
Operating Budget for Entire Agency
AGENCY NAME: Chapel Hill Training- Outreach Project, Inc. (KidSCope)
AGENCY REVENUE
Private Donations
Agency Generated Revenue (fees)
Local Government Grants:
Orange County
Town of Chapel Hill
Town of Carrboro
Chatham County
Other Local: Strowd Roses
Other Local: Duke Corp
Other Local: Misc
provide a separate list.
Other Government Grants
Triangle United Way
State Government
Federal Government
Other Grants: NC Pre -K
Other Grants: CACFP
Miscellaneous/Other Revenue
Please list 3 largest Miscellaneous sources 17 -18:
Total Agency Revenue
AGENCY EXPENSES
Compensation
Rent & Utilities
Supplies & Equipment
Travel & Training
Other Expenses:
Please list 3 largest "Other Expenses" 17 -18:
Indirect Cost to CHTOP, Inc $114,092.00
Contracted Services $ 79,180.00
Rent & Utilities $ 89,904.00
Total Agency Expenses
SURPLUS /(DEFICIT) FOR PERIOD: 1 ($113,994) ($45,674) ($45,674) 0%
h) Agency Budget
Agency Information 1/22/2018 3:23:54 PM Ij --3 g e 1 3 o f
Actual
2016 -17
Estimated
2017 -18
Projected
2018 -19
Percent
Change
$
8,777
$
11,500
$
11,500
0%
$
1,019,027
$
785,654
$
785,654
0%
$
75,000
$
75,000
$
75,000
0%
$
4,500
$
4,500
$
4,500
0%
$
2,200
$
2,200
$
2,200
0%
$
1,750
$
5,000
$
5,000
0%
$
4,081
0
$
$
479
57,768
$
58,068
$
58,068
0
0%
0
$
374,744
$
388,624
$
388,624
0%
$
175,675
$
118,000
$
118,000
0%
$
73,701
$
52,600
$
52,600
0%
$
$
329,694
396
M2127
,,288
$
$
$
335,163
1 836 309
1,398,890
$
$
$
335,163
1 836 309
1,398,890
00
0%
0%
$
103,080
$
110,025
$
110,025
0%
$
77,083
$
64,325
$
64,325
0%
$
28,514
$
32,106
$
32,106
0%
$
387,426
$
276,637
$
276,637
0%
2,241,391
1,881,983
1,881,983
0%
SURPLUS /(DEFICIT) FOR PERIOD: 1 ($113,994) ($45,674) ($45,674) 0%
h) Agency Budget
Agency Information 1/22/2018 3:23:54 PM Ij --3 g e 1 3 o f
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E713D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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 requests /awards /totals from Carrboro, Chapel Hill,
and Orange County governments (other than Human Services). DO NOT include federal
funding sources, such as CDBG and HOME.
Program
FY17 -18
Award
FY18 -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
As file) or you may submit your own budget file (as long as it contains the same
information, and in a similar format, as requested in the provided template).
Agency Budgets are required to define budget amounts for the previous program
year, current program year, and next program year for the following categories:
Revenues
• Private Donations
• Program Generated Revenue
• Local Government Grants
• Carrboro Human Services
• Carrboro Other
• Chapel Hill Human Services
• Chapel Hill Other (DO NOT include CDBG funding here)
• Orange County Human Services
• Orange County Other (DO NOT Include HOME funding here)
• Other Government Grants
Agency Information 1/22/2018 3:23:54 PM Page 14 of 27
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
• Triangle United Way
• State Government
• Federal Government (CDBG /HOME /etc.)
• 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? Deficit
Is there a significant change? Yes /No No
Please provide a brief explanation for Surplus or Deficit, and significant changes
Decreases in Medicaid reimbursement rates still represent an annual loss of funding, and
threaten our ability to serve all of the children referred. Medicaid funding is a large part of
our revenue. Although we are successful at accessing Medicaid funds, the entire mental
health system is remains underfunded and fragile. The volatility of the federal, state, and
local economic picture continues to threaten our funding as well. The uncertainly of the
future of the mental health system under DHHS, including the possibility of outsourcing
mental health /Medicaid to the private sector, has everything on hold. Until this crucial
decision is resolved, issues regarding rate increases and development and implementation
of new services will remain unstable.
iv. What is your agency's fiscal year? June 30, 2018- July 1, 2019
(Example: July 1, 2016 through June 30, 2017)
Agency Information 1/22/2018 3:23:54 PM
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E713D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
3. PROGRAM INFORMATION (Submit a separate Section 3 for each program)
Program Name: KidSCope Community Outreach
Program Primary Contact and Title: Linda Foxworth, Director
Telephone Number:919- 644 -6590/ 919 - 656 -3213 (cell)E- Mail:l foxworthCc)_kidscope.chtop.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
® 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
Education
x
Family Resources
x
Jobs /Jobs Training
Food
Transportation
Other: Please specify
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.
KidSCope coordinates services with the similar programs and agencies in order to
ensure that children in need are identified and referred in a timely, efficient manner.
These agencies include:
• Children's Developmental Services Agency (CDSA)
• Orange County Departments of Social Services and Health
• Child Care Services Association
• Family Success Alliance, Making Connections (United Way Collaboratives)
• Orange County Partnership for Young Children
• Orange County Schools/ Chapel Hill /Carrboro City Schools
• Head Start /Early Head Start
• Cardinal Innovations
PROGRAM INFORMATION 1/22/2018 3:23:54 PM Page 16 of 27
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
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?
KidSCope proposes the following services:
• Customized assessment and evaluation for children ages birth to 5, and their families,
to determine strengths and needs,
• Social- emotional /behavioral health services using researched, evidence -based
treatment modalities providing both home visiting and office -based options. These
programs are designed to give children a healthy start in the early years when
relationships and experiences influence brain development the most.
• Parent education that encourages and supports positive family relationships and
interactions, particularly in the early years. These programs include the Incredible
Years Basic /Incredible Toddlers.
By proposing these services-
KidSCope addresses Orange County Goal 1, Priority Four, Protect Safety Net
Programs
• KidSCope addresses all three priority areas for the Town of Chapel Hill
• KidSCope addresses the Town of Carrboro's Goal of Improving Services for
Citizens
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 poverty rate has increased in Orange County since 2009 from 9.4% to 15.8%
in 2015, according to the statistics obtained from the 2017 update of the US
Census report. According to data provided to the Family Success Alliance of
Orange County by the Frank Porter Graham Child Development Institute, Orange
County ranks first in the state in income inequality. Additionally, according to
FPGCDI, 16% of Orange County residents live in poverty. 14% of children live in
poverty and 75% of children born in poverty will remain there, or in low income
households into adulthood. In early childhood, research on the biology of stress
indicates that major adversity, such as extreme poverty, above, or neglect can
affect brain development and permanently set the child's stress level on high alert.
Chronic stress can be toxic to the brains of young children.
PROGRAM INFORMATION 1/22/2018 3:23:54 PM ' a g e 17 o f 2
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
The Chapel Hill Human Needs Assessment identified Affordable Healthcare and
Education and Family Resources as key human needs and priorities for funding.
Orange County Goals
Goal 1: Ensure a community network of basic human services and infrastructure
that maintains, protects, and promotes the well -being of all county residents.
Goal 6
Ensure a high quality of life and lifelong learning that champions diversity,
education at all levels, libraries, parks, recreation, and animal welfare
KidSCope is a collaborative partner with FAMILY SUCCESS ALLIANCE.
KidSCope provides access to developmental and mental health screening and
services, and parent education resources to increase positive parenting skills.
f) Who is your target population of individuals to benefit from this program and how will they be
identified and connected with the program?
KidSCope provides mental health and family support to children birth to 5 and their
families in Orange County. KidSCope services prepare families for positive early
experiences that "scaffold" healthy development, and build a foundation for later
skills and learning capacities.
Families may self- refer, or referrals may be made by other agencies such as
Cardinal Innovations, Orange County Department of Social Services, Orange
County Health Department, local child care programs, Head Start and Early Head
Start, School Systems, medical facilities, the court system, or a variety of other
sources. Ultimately, families /guardians make the decision to receive services.
g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program
Manager and credentials, describe training provided to volunteers, etc.)
Linda Foxworth is the founder of the KidSCope program and has been its director
since 1988. Linda has more than 40 years of experience working with young
children with special needs and their families. As Director of KidSCope in Orange
and Chatham Counties, Linda has been responsible for administration of programs
that provide mental health and developmental disabilities services for young children
and families. Linda has a BA in Sociology and Master's Degree in Special
Education, specializing in Early Childhood Handicapping Conditions.
Kathy Eden is the KidSCope Outreach Clinical Coordinator and is a Licensed
Clinical Social Worker whose specialty is children and families. Kathy has a family -
focused approach with the goal of strengthening parent skills and knowledge to help
children meet their developmental potential. She also specializes in working with
children with autism and their families and has worked for KidSCope since 2007.
KidSCope Outreach volunteers participate as members of the KidSCope Advisory
Council. They are not directly involved in providing services to families. Volunteers
are trained in all program functions and activities annually.
PROGRAM INFORMATION 1/22/2018 3:23:54 PM Pa g e 18 0 f 7
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
h) Describe the specific period over which the activities will be carried out and include an
implementation timeline.
Program activities will be carried out from July 1, 2018 -June 30, 2019 according to the
following time line:
Timeline
Task /Activity
Responsible Party
July, 2018 - August 1,2018
Develop public awareness info
Therapists/ intake staff
July 1, 2018 -June
Distribute flyers /referral info to
Therapists, intake and
30,2019
community partners
other KidSCope staff
July 1,2018 -June 30,2019
Accept referrals to program
Therapists
July 1,2018- June30,2019
Administer Pre -tests
Therapists
July 1,2018 -June 30,2019
Provide services
Therapists
July 1,2018 -June 30,2019
Provide Post -tests to families
Therapists
when they complete services or
every 6 months
July 15, 2018 - September
Administer surveys to participants
Therapists and
30, 2018
at exit of services, or end of the
administrative staff
fiscal year. Analyze data for
Advisory Council and reports
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)
KidSCope interventions speak to families "where they are" because they focus on the
development of healthy family relationships. KidSCope provides access to health care
services for those who have Medicaid, private insurance or are uninsured. The
groundbreaking studies of economist/ Professor James Heckman show that "high
quality birth -to -five programs for disadvantaged children can deliver a 13% per child,
per year return on investment through better outcomes in education, health, social
behaviors and employment, reducing taxpayer costs down the line and preparing the
country's workforce for a competitive future ". KidSCope is the only non - profit
oraanization in Oranae Countv desianed to provide developmental. mental health and
social - emotional support to children birth to five. their families. and care Droviders.
j) Describe what would happen if requested funding is not awarded at all or if a reduced
allocation is recommended.
Although we would continue to seek funding from other sources, if funding is not
received through this application for the KidSCope Community Outreach program, the
program will not be viable, or available to Orange County children and families.
PROGRAM INFORMATION 1/22/2018 3:23:54 PM
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E713D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
k) What percentage of your target population is low- moderate income?
The low- moderate income rates are: 87% for Outreach Program, and 94% for the
early childhood program.
1) What efforts do you make to seek feedback about your program from your target population
(e.g. survey, evaluations, etc. ?)
KidSCope seeks feedback in the following ways:
• Therapy services include assessment start of services and at appropriate intervals of
the child /family to determine outcomes.
• Families are surveyed at the completion of services to determine program
satisfaction, and to inform changes and updates of services.
m) Include any other pertinent information. None noted.
PROGRAM INFORMATION 1/22/2018 3:23:54 PM Page 20 of 27
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D
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, Biracial, Arab, unspecified
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
47
55
65
27
35
45
74
90
110
14
18
25
1
1
0
0
4
5
29
37
40
0
0
0
30
30
40
74
90
110
21
27
37
53
63
73
74
90
110
74
90
110
0
0
0
0
0
0
0
0
0
74
1 90
110
1
1
0
0
0
0
0
0
0
0
0
0
0
0
5
18
25
30
8
17
20
13
14
15
6
3
6
28
30
34
Total 1 74 90 1 110
PROGRAM INFORMATION 1/22/2018 3:23:54 PM Page 21 of 27
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E713D
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 (Specific, Measurable, Achievable, Relevant, and _Time-bound. Click
on SMART Goals to learn more.
• Program Activities should outline major activities the agency implements to accomplish its
program goals. (i.e. Deliver meals to elderly /disabled residents.)
• Program Goal should explain what the program is trying to achieve /accomplish. Goals are
statements about what the program should accomplish. (i.e. Deliver 100 meals per day,
Monday- Friday.)
• Performance Measures describe how you will evaluate the degree in which you achieved
the stated goals. (i.e. Will track the number of meals delivered each day.)
• Actual Program Results use program results to indicate the actual measureable
achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of
105 meals per day.)
Work Statement Chart for Program KidSCope
1. Program Activity Name
Assessment
Program Goal
Assess 110 children birth to 5 to determine needs
Performance Measures
100 children will be assessed
Previous Year Program Results
74 children were assessed
Current Year Estimated Results
100 will be assessed
Next Year Projected Results
Provide to 110 children
2. Program Activity Name
Provide Evidence Based therapeutic interventions to improve
behaviors
Program Goal
Provide to 100 children and family members
Performance Measures
Provide to 94 children and family members
Previous Year Program Results
Provided to 74 children and their families
Current Year Estimated Results
Provide to 100 children and families
Next Year Projected Results
Provide to 100 children and their families
3. Program Activity Name
Provide counseling /education to families to increase knowledge of
successful parenting and promote positive relationships
Program Goal
110 children and their family members
Performance Measures
Provide to 100 children and their family members
Previous Year Program Results
Provided to 74 children and their family members
Current Year Estimated Results
Provide to 100 children and their family members
Next Year Projected Results
Provide to 110 children and their family members
4. Program Activity Name
Program Goal
Performance Measures
Previous Year Program Results
Current Year Estimated Results
Next Year Projected Results
PROGRAM INFORMATION 1/22/2018 3:23:54 PM Page 22 of 27
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
Program Budget
Operating Budget for Program
AGENCY NAME: Chapel Hill Training- Outreach Project, Inc. (KidSCope)
PROGRAM REVENUE
Private Donations
Program Generated Revenue (fees)
Local Government Grants:
Orange County
Town of Chapel Hill
Town of Carrboro
Chatham County
Other Local: Strowd Roses
Other Local: Misc
provide a separate list.
Other Government Grants
Triangle United Way
State Government
Federal Government
Other Grants:
Other Grants:
Miscellaneous/Other Revenue
Please list 3 largest Miscellaneous sources:
Total Program Revenue
PROGRAM EXPENSES
Compensation
Rent & Utilities
Supplies & Equipment
Travel & Training
Other Expenses:
Please list 3 largest "Other Expenses ":
Indirect cost to CHTOP, Inc. $ 7,957.00
Occupancy costs $ 800.00
Computer Maintenance $ 5,000.00
Total Program Expenses
SURPLUS /(DEFICIT) FOR PERIOD: 1 ($59,905) ($26,878) ($26,878) 0%
p) Program Budget
PROGRAM INFORMATION 1/22/2018 3:23:54 PM P a g e 23 of 27
Actual
2016 -17
Estimated
2017 -18
Projected
2018 -19
Percent
Change
$
8,557
$
11,000
$
11,000
0%
$
21,024
$
21,000
$
21,000
0%
$
75,000
$
75,000
$
75,000
0%
$
4,500
$
4,500
$
4,500
0%
$
2,200
$
2,200
$
2,200
0%
0
$
5,000
$
5,000
0%
0
$
-
$
-
$
-
0
0
0
0
0
0
$
$
111 281
110,129
$
$
118 700
88,407
$
$
118 700
88,407
0%
0%
$
17,936
$
24,834
$
24,834
0%
$
2,202
$
2,600
$
2,600
0%
$
6,224
$
9,000
$
9,000
0%
$
34,695
$
20,737
$
20,737
0%
$ 171,186
$ 145,578
$145,578
V0
SURPLUS /(DEFICIT) FOR PERIOD: 1 ($59,905) ($26,878) ($26,878) 0%
p) Program Budget
PROGRAM INFORMATION 1/22/2018 3:23:54 PM P a g e 23 of 27
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E76D
EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION
1. Submit your program budget. You may complete the provided template (separate xls
file) or you may submit your own budget file (as long as it contains the same information,
in the same format, as requested in the provided template).
Program Budgets are required to define budget amounts for the previous program
year, current program year, and next program year for the following categories:
Revenues
o Private Donations
• Program Generated Revenue
• Local Government Grants
• Carrboro Human Services
• Carrboro Other
• Chapel Hill Human Services
• Chapel Hill Other (DO NOT include CDBG funding here)
• Orange County Human Services
• Orange County Other (DO NOT Include HOME funding here)
• Other Government Grants
• Triangle United Way
• State Government
• Federal Government (CDBG /HOME /etc.)
• Private Foundation Grants
• Other Revenue
Expenditures
• Compensation
• Rent & Utilities
• Supplies & Equipment
• Travel & Training
• Other Expenses
2. Program Budget Detail — Provide description of "other" budget items, not defined.
None noted.
3. This program budget represents what percent of the agency budget? 8%
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 3:23:54 PM
Actual 2016 -17
Estimated 2017 -18
Projected 2018 -19
Total Cost of Program
$171,186
$145,578
$145.578
Total # of Individuals
185
225
275
Cost Per Individual
$925.33
$647.00
$529.37
PROGRAM INFORMATION 1/22/2018 3:23:54 PM
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E7BD
EXHIUBIT "B"
Scope of Services — FY 2018 -19
Outside Agency Performance Agreement
Agency Name; Chapel Hill Training Outreach Project, lnc.
Program Name; ]KidSCope
Funding Award: $75,000
Outline how the agency will spend Orange County's funding award.
Expense Description
Amount
Salary and benefits for staff to implement the program-
$75,000
By June 30, 2019, 75% of children served by KidSCope Outreach will show improvement in
behavior and social skills
75/100
By June 30, 2019, 95% of families surveyed will report improvement in their child's ability to get
along better with children and adults
95% of
those
surveyed
By June 30, 2019, 97 %Q of parents surveyed will report learning new parenting stratgies and
understanding of child development.
97% of
those
serve ed
Program Services
Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2019.
• Assess/evaluate children who are referred to the KidSCope Program to determine needs
• Provide therapy or other individual /family interventions to support positive primary relationships
for children and to improve behavior and social skills.
• Provide parent education to families to increase knowledge of successful parenting.
Anticipated Outcomes
The Anticipated Results column must include quantifiable results in the form of number of persons /units served within Orange
County, on[ y (all Towns and municipalities). I € you use percentages, you must also provide the total number of narticinants
within that measure's descriotiion or for an earlier performance measure.
Performance Measures
Anticipated
Results
By June 30, 2019, 100 children of 110 referred will receive evidence based assessment
100 /110
By June 30, 2019, 75% of children served by KidSCope Outreach will show improvement in
behavior and social skills
75/100
By June 30, 2019, 95% of families surveyed will report improvement in their child's ability to get
along better with children and adults
95% of
those
surveyed
By June 30, 2019, 97 %Q of parents surveyed will report learning new parenting stratgies and
understanding of child development.
97% of
those
serve ed
DOCUSIgnedby:
Executive Director 8/16/2018
'-tC 111
`4FS9DHW41148C... �� at % 9
Certified y:. Title: J e:
(Provider's Signature)
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E7BD
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.
oacusigned by:
Certified by: _ 3C41 148C.. —
(Provider's Signature)
Executive Director
Title:
Date:
8/16/2018
(KidSCope: Chapel Hill Training Outreach Project, Inc.)
Orange County Outside Agency Performance Agreement Page 9 of 9
Rev. 7118
DocuSign Envelope ID: E7784BE7- 82AF- 4AF1- AA11- 944D2300E7BD
Client #: 929075
20CHAPEHIL3
ACORD,,, CERTIFICATE OF LIABILITY INSURANCE
DATE (MM /DD /YYYY)
07/24/2018
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 any rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
McGriff Insurance Services, Inc.
Post Office Box 13941
Durham, NC 27709
919 281 -4500
CONTACT
NAME: Beth Wilkerson
PHONE 919 281 -4500 FAX 888 746 -8761
Lo Ext : AIC, No
-MA
ADDRESS: bcwilkerson @mcgrifflnsurance.com
INSURER(S) AFFORDING COVERAGE
NAIC#
INSURER A: Philadelphia Indemnity Insurance Co.
O
1 $058 8
INSURED
Chapel Hill Training Outreach Pil Inc
800 Eastowne Dr Ste 105
INSURER B : Progressive Southeastern In—noe Co.
38784
INSURER C Ac.identFtmd In. C.OfAmerica
10166
$1,000,000
Chapel Hill, NC 27514
INSURER D:
INSURER E :
INSURER F:
PREMISES Ea occurrence)
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
WVD
POLICY NUMBER
POLICY EFF
MM /DD /YYYY
POLICY EXP
MM /DD
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
X
PHPK1774361
2/05/2018
02105/201
EACH OCCURRENCE
$1,000,000
CLAIMS -MADE [X OCCUR
PREMISES Ea occurrence)
$1,000,000
MED EXP (Any one person)
$20,000
PERSONAL & ADV INJURY
$1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 3,000,000
PRO-
POLICYFI JECT F7 LOC
PRODUCTS - COMP /OP AGG
$ 3,000,000
$
OTHER:
B
AUTOMOBILE
LIABILITY
065151020
2/05/2018
02/05/201
Ea accideD SINGLE LIMIT
$2,000,000
BODILY INJURY (Per person)
$
ANY AUTO
OWNED X SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
A
X
UMBRELLA LIAB
X
OCCUR
PHUB617091
02/05/2018
02/05/2019
EACH OCCURRENCE
$1,000,000
AGGREGATE
$1,000,000
EXCESS LIAB
CLAIMS -MADE
DED X RETENTION $10000
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N
OFFICERIMEMBER EXCLUDED? I NI
NIA
WCV6096247
12/17/2017
121171201
X PER OTH-
STATUTE IER
E.L. EACH ACCIDENT
$500 OOO
E.L. DISEASE - EA EMPLOYEE
$500 OOO
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$500,000
A
Professional Liab
PHPK1774361
2/05/2018
02/05/201
$1,000,0001$3,000,000
A
Cyber Liability
PHSD1319124
02/05/2018
02/05/201
$1,000,000/$2,000,000
A
Abuse /Molestation
PHPK1774361
02/05/2018102/05/201
$1,000,000/$3,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
** Workers Comp Information **
Other States Coverage
Certificate Holder is included as Additional Insured, per written contract, as their interest may appear
I.CK 1 Ir ILA 1 t nULUtr(
Orange County Government
Finance & Admin Services
Attn: Allen Coleman
200 S Cameron St; PO Box 8181
Hillsborough, NC 27278
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ne TPIRR -2015 ACORD CORPORATION. All rights reserved
ACORD 25 (2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD
#S20688104/M20687965 BG3