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2018-450-E Finance - Table outside agency agreement
DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 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 TABLE, a not - for -profit corporation, located at 209 East Main Street, Carrboro, NC 27510 ( "Provider "). 1.T /MM01=4so I I I 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 TABLE 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 $10,450. 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 $2,612.50. 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. (TABLE) Orange County Outside Agency Performance Agreement Revised 712018 Page 1 of 9 DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 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. (TABLE) Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 7118 DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 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. (TABLE) Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 7118 DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 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 TABLE 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: (TABLE) Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 7118 DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 County: Finance & Administrative Services Provider: TABLE Orange County 209 East Main Street Post Office Box 8181 Carrboro, NC 27510 Hillsborough, NC 27278 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 Uocusigned by: he Provider 110F9A4EFC1A6141A S bVL I , fftK.S ... Fo, Docu5ignedby, County Government 661n AV (' �"t wtc i" 0637994B755E477... Bonnie Hammersley, County Manager (TABLE) Orange County Outside Agency Performance Agreement Rev. 7118 8/16/2018 Date 8/17/2018 Date Page S of 9 DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Table Ministries, Inc. Applicant Organization's Physical Address: 209 E. Main Street, Carrboro, NC 27510 Applicant Organization's Mailing Address: same as above Applicant Organization's Web Address: www.tablenc.org Executive Director: Ashton Tippins Telephone Number: (919)636 -4860 E -Mail: info(a)tablenc.org Tax ID Number: 26- 1471735 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 Carrboro Chapel Hill - HS Orange County -HS Total - HS Ex. Youth Afterschool Program Afterschool Program Coordinator salary and materials for youth activities and projects $10,000 $15,000 $5,000 $30,000 Food 9000 9000 9000 27000 Program Staff Support 3000 3000 3000 9000 Rent 3000 3000 3000 9000 Totals 15,000 15,000 15,000 $45,000 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: ' �1t✓ ,� � 1 Executive Director I t�� Signature: B and Cha' person 1/19/18 Date 1/23/18 Date AGENCY INFORMATION 1/23/2018 3:44:19 PM Page 7 of 21 DocuSign Envelope ID: 2AC82140-8F6C-4125-8743-OB8594E61466 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? ❑ ® 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: Ex cutive Dire Signature: I 1/19/18 Date 1/23/18 Date AGENCY INFORMATION 1/23/2018 3:44:19 PM P a g e 8 of 21 DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION TABLET feeding local hungry kids Agency Information Years in Operation, Date of Incorporation, Agency's Purpose /Mission, Types of Services the Agency Provides Joy MacVane and several UNC students founded TABLE in November 2007 (incorporated on the 21St). Our founders recognized the prevalence of hungry children in the Chapel Hill - Carrboro area and noticed that there were no food assistance services for children. Our Mission is to bring together UNC college students and local community members to feed hungry children in Chapel Hill and Carrboro. TABLE has three goals: to provide weekly emergency food aid to local hungry children, to educate and expose our little ones to healthy foods and eating habits, and increase community awareness of local childhood hunger. TABLE is a 501(c)(3) non - profit organization that began feeding 12 local elementary school children in 2008 and has since expanded to provide healthy food to more than 600 preschool, elementary, and middle school children each week. TABLE has four programs to support its mission and goals: 1) The Weekend Meal Backpack Program (WMBP) provides healthy non - perishables, local fresh produce and fresh milk to children that are at risk of hunger on weekends and school holidays. 2) SnackChef exposes our children to fresh foods and teaches them how to make easy, healthy snacks at home. 3) Summer TABLE provides healthy food to local kids for 10 weeks in the summer 4) TABLE On the Go (our newest program) allows children the opportunity to visit local farms, farmer's markets, and community gardens so they may learn about healthy food, their community, and where their food comes from. Agency's History with Providing These Services: TABLE has been delivering emergency food to hungry children in Chapel Hill and Carrboro since spring of 2008. Below we have outlined our ten year commitment to providing healthy food to local kids: 2007: TABLE was incorporated in November. 2008: TABLE started delivering non - perishable food to 12 local elementary school children each week. 2010: TABLE began incorporating local produce every week into our bags of healthy food due to collaboration with Farmer Foodshare. 2013/2014 School Year: TABLE's Weekend Meal Backpack Program provided weekly emergency food aid to 226 local hungry children. That's over 3 tons of food each month! 2014/2015 School Year: TABLE expanded its programming to include kids in preschool, elementary school, and middle school (3 years - 14 years)! TABLE began to serve 400 kids each week in February 2015. DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Fall 2015: TABLE began serving healthy food to 500 kids each week through our Weekend Meal Backpack Program! 2015/2016: TABLE receives data through surveys that kids are able to perform better in school and eat healthier due to the weekly food that TABLE provides. Additionally, in order to better impact kids, we seek food preferences of the children we serve. 2017/2018: TABLE delivers healthy food to 600+ children every week and provides nutrition education to 325 kids through SnackChef. During our ten years, TABLE has had the following track record of success: 1) Success in providing healthy food and nutrition education to local hungry children through our four programs. During the 2016/2017 school year, we expanded our participating children roster to 555 children, and we distributed over 56 tons of healthy food to local kids through the WMBP. Our 2017 Summer Program (similar to WMBP) provided healthy food to 482 children each week. Our SnackChef Program currently provides healthy snacks to 325 children during the school year, teaching them how to make nutritious snacks, try new foods, and eat healthy while empowering them to teach others. 2) Success in maintaining sustainability and connecting with the local community. In the last 5 years, TABLE has hired new staff, more than tripled our services to local children, and still increased income annually in order to continue the growth and improvement of each of our programs. 3) Success in forming efficacious partnerships and collaborations. TABLE works with a vast number of local organizations, businesses, schools, other non - profits to better serve our kids as well as the community at large. We are honored to be able to serve the Chapel Hill - Carrboro community and thankful for the partnerships and support that make it possible! 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 ?) TABLE moved from 205 W. Weaver Street in Carrboro to a new, larger location at 209 E. Main Street in Carrboro on February 1, 2017. This has allowed us to feed additional children and increase partnerships with local businesses and organizations. We will be at this location for at least 12 more months with a possibility of extending our lease 12 additional months. DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description Summarize the program services proposed and how the program will address a Town /County priority /goal? The Weekend Meal Backpack Program (WMBP) is TABLE's school year hunger relief program for hungry children living in Chapel Hill and Carrboro, NC. Currently, 30% of kids in the Chapel Hill - Carrboro School System (preschool, elementary and middle schools) rely on free and subsidized school breakfasts and lunches during the week. Consequently, they often go hungry on weekends and school vacations when those free meals are not available. TABLE works to meet their need for emergency healthy food during those times. At the end of each week, TABLE distributes fresh produce and healthy non - perishables to participating kids. Receiving this emergency food aid each week allows children to return to school Mondays not ravenous - but ready to learn. TABLE's WMBP primarily addresses the Town /County priority to improve health and nutrition of local kids by providing them with healthy non - perishables, produce, and fresh milk every single week. According to a pool of surveyed parents in spring 2017, below is some of the information we learned about children who had been participating in TABLE's WMBP for more than one year: Children always tried new food 38% of the time before receiving healthy food from TABLE. After receiving weekly food from TABLE, children always tried new foods 62% of the time. Children always ate healthy foods 59% of the time compared to 74% after participating in TABLE's WMBP. 41 % of children were eating junk food all the time before receiving food from TABLE compared to 26% after participating in the WMBP. Secondarily, however, it is evident that the WMBP directly addresses the other two Town /County priorities as well: 1) WMBP improves the opportunity for a good education for local kids because they are able to focus on their schoolwork instead of their grumbling bellies as well as miss fewer school days because of frequent sickness. According to parent responses in this same survey, TABLE also saw a 12% increase in children getting above average grades after participating in TABLE's WMBP for more than one year. This is the second year that we have measured this data with positive results and we will continue to measure it annually. 2) WMBP also serves as a safety - net for parents and families of children because it allows parents to put more of their funds toward other bills like rent, utilities, fuel or transportation, providing families with additional opportunities they may not otherwise have. 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. TABLE's hunger relief programs target food - insecure preschool, elementary, and middle school children living in Chapel Hill and Carrboro, NC. During the current 2017/2018 school year, the Chapel Hill- Carrboro School System let us know that 30% of children DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION attending their schools were enrolled in the National School Lunch Program suggesting that nearly 1 in 3 local children are 1) at risk for hunger on weekends and other times of the year when schools meals are not available and 2) have limited access to fresh food because of expense and access issues. The breakdown of this statistic is as follows: • 32% of preschool and elementary school children • 25% of middle school students That's more than 2,500 kids that are likely going hungry on weekends and school holidays when they do not have access to their free school breakfasts and lunches. The Town and County priorities all have some focus on provision of healthy food for low- income residents and /or providing a home for residents to feel mutually respected. All priorities also seek infrastructure improvements for the town /county to be successful, reduce crime, improve economic growth, etc. Children not having enough food is directly related to the success of our towns and county. Our kids are not simply at risk for being hungry on weekends, but also low academic performance, inappropriate behavior, low self- esteem, and health problems. Kids cannot grow up to be successful, thriving adults under these conditions. They MUST have their basic needs fulfilled before they even stand a chance of performing well in school, behaving appropriately, having strong relationships, and strong, healthy bodies. The growth, prosperity, and success of our towns and county depend fully on the growth of our children into productive adults. Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? TABLE provides healthy food every week to preschool, elementary, and middle school children living in Chapel Hill and Carrboro. All children participating in our hunger relief programs live in local low- income communities. About 97% of the children we serve represent racial and ethnic minority populations. To reach local food - insecure children, TABLE partners with 35+ community organizations to provide healthy food to those kids through the WMBP. TABLE identifies the beneficiaries of our program by partnering with staff and faculty at our numerous partner locations. School social workers and after school staff help us identify children and families that are in need as well as distribute and gather permission forms. At public housing facilities, our staff and volunteers walk door -to -door to offer our services. At all of our locations, parents simply need to fill out a permission form for their child to receive healthy food every single week. Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) The Program Director of our WMBP graduated from UNC -CH in 2012 with her B.A. in Sociology. She served as a Volunteer Coordinator for UNC Hospitals preparing her for her work at TABLE. She has been serving as TABLE's Program Director since April 2013. Since that time she has grown the number of children served from 170 to 600 children weekly. All Team Leaders undergo an orientation about TABLE, their responsibilities, and local childhood hunger. They also undergo an individual training session lead by the Program Director about their volunteer shift. Additionally, we are just beginning to provide bi- DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION annual opportunities for our volunteers to attend an orientation to learn about hunger, TABLE, and how they can get involved in helping us feed kids! Describe the specific period over which the activities will be carried out and include an implementation timeline. Planning for our WMBP begins in mid - August. Delivery of food will be carried out from mid - September 2018 until the first week of June 2019. We will be delivering bags of healthy food to kids at their school, after school center, or apartment home every week. This program has been executed for ten years. We begin reaching out to new and current partner agencies in August /early September. By mid - September we make our first delivery. We continue to add new children to our roster and increase the number of children served throughout the school year. 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) Funding TABLE's WMBP is a good investment because we all want our communities to succeed. Our community success is dependent on the success of the individuals within our community. Our surveys show that kids are able to perform better in school and eat healthier when their nutritional needs are met (see Town Priority question above). And, we do expect to see those numbers increase as we are able to track a trend in a few more years. As you all know, there is an achievement gap in our schools among racial minorities and Caucasian children. In addition to other challenges they may be experiencing, these kids may often be experiencing poverty and hunger. It is no surprise that 97% of children that TABLE serves represent racial and ethnic minority populations. In order to improve performance at school, certainly kids should receive equitable treatment in our schools, but we cannot overlook the requirement to fulfill their basic needs either. How many of us can perform well in anything when we experience persistent hunger? Our children shouldn't have to experience persistent hunger either. Help us help our kids succeed! Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Currently, there are more than 2,500 children in Chapel Hill- Carrboro City School that are receiving free /reduced school lunches. TABLE is serving 600 of these children. If TABLE does not receive funding from the Towns and County, we will have to work harder to acquire additional funding and we may not be able to increase our capacity in 2018 -2019 and in coming years to serve additional children in our communities. This could delay our goal to deliver healthy food to hungry children in northern Orange County, as well as provide nutrition education field trips and interactive classes. What percentage of your target population is low- moderate income? 99% of known income levels are low- moderate income. 27% of our families left the answer to this question blank. What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc. ?) We welcome feedback year- round. We actively seek feedback annually from the families that we serve, the children who participate in our nutrition education programs, DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION our volunteers, and our partner sites. We are also in the planning stages of developing relationships with some of the families we serve in order to create meaningful interaction and gain the most useful feedback so we can better serve our community. While we know that our work is valuable to our community, we also know that innovation and problem solving can provide unique opportunities to better serve individuals and the community as a whole. Include any other pertinent information. TABLE's long -term plan is to provide healthy food to every single child in Chapel Hill - Carrboro that is hungry. In the coming years, we would love to focus on providing and /or partnering with other organizations to provide the children in Hillsborough, Mebane, Efland, and other surrounding communities with the healthy food they need. We recognize that there is a major need and that TABLE could make a difference for the children in the remainder of our County. But, we need the support of our local governments (as well as local individuals, organizations, and businesses) to be able to meet that goal sooner rather than later. The longer it takes for us to acquire program and operational funding, the longer kids have to wait to have full bellies, get good grades, have high self- esteem, be healthy, etc. Please stand alongside TABLE to provide healthy food to our community's children. We appreciate your consideration. DocuSign Envelope ID: 2AC82140-8F6C-4125-8743-OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION • 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 iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes /No Please provide a brief explanation for Surplus or Deficit, and significant changes. TABLE is operating on a surplus for a few reasons: 1) We are planning to purchase or lease permanent space in the next 1 -2 years. We expect to have to upfit the space that we select to meet our basic needs (i.e. Walk -in cooler, conference space, loading dock, etc.). We need significant funding to do so. 2) Our operating expenses increase every year because we are serving more children. In order to continue to increase the children we serve in our nutrition education and hunger relief programs, we must be sure that we maintain a steady stream of funding. The surplus allows us the confidence to increase the children we serve and fund improvements to our programs. iv. What is your agency's fiscal year? September 1, 2016 - August 31, 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/23/2018 3:44:19 PM DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Weekend Meal Backpack Program Program Primary Contact and Title: Laura Dille Telephone Number: (919)636 -4860 E -Mail: Idille(a)tablenc.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 Education Family Resources Jobs /Jobs Training Food X Transportation Other: Please specify Nutrition Education 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. • McDougle Elementary School: Provide information /support to feed attending kids. • Frank Porter Graham Elementary School: Provide information /support to feed attending kids. • Ephesus Elementary School: Provide information /support to feed attending kids. • Estes Hills Elementary School: Provide information /support to feed attending kids. • Mary Scroggs Elementary School: Provide information /support to feed attending kids. • Rashkis Elementary School: Provide information /support to feed attending kids. • Seawell Elementary School: Provide information /support to feed attending kids. • Carrboro Elementary School: Provide information /support to feed attending kids. • McDougle Middle School: Provide information /support to feed attending kids. • Culbreth Middle School: Provide information /support to feed attending kids. PROGRAM INFORMATION 1/23/2018 3:44:19 PM DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION • Phillips Middle School: Provide information /support to feed attending kids. • Smith Middle School: Provide information /support to feed attending kids. • Chapel Hill - Carrboro City Schools Pre -K /Head Start Program: Provide information /support to feed attending kids. • Dobbins Hill Family Resource Center: Provide information /support to feed attending kids. • Town of Chapel Hill (Public Housing Facilities): Provide information /support to feed attending kids. • El Centro Hispano: Provide information /support to feed attending kids. • Hargraves Community Center: Provide information /support to feed attending kids. • Communiversity: Provide information /support to feed attending kids. • Rogers- Eubanks Neighborhood Association: Provide information /support to feed attending kids. • Street Scene Teen Center: Provide information /support to feed attending kids. • Maple View Farms: Donate fresh milk every week to kids through WMBP. Also partnered to create a field trip opportunity for our kids. • Farmer Foodshare: Partner to provide purchased and donated fresh food to kids via WMBP. • Weaver Street Market: Help us raise funds /food for programs. Provide services for TABLE to purchase food for WMBP and Summer TABLE. • Food for the Summer: Help us to efficiently reach and serve additional children in the summer. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: See attachment d) Summarize the program services proposed and how the program will address a Town /County priority /goal? 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. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) PROGRAM INFORMATION 1/23/2018 3:44:19 PM P a g e 13 of 2 1 DocuSign Envelope ID: 2AC82140-8F6C-4125-8743-OB8594E61466 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 Unknown Total Ethnicity African - American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: Multi- racial or Unknown Total Of the above, how many Hispanic /Latino Of the above, how many non - Hispanic /Latino Total Age Geographic Location 0 -5 years 6 -18 years 19 -50 years 51 + years Unknown Total 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 -19 269 299 350 249 37 280 37 330 20 555 616 700 192 203 226 0 1 7 108 130 173 174 177 196 0 3 8 81 102 90 555 616 700 132 143 155 423 473 545 555 616 700 37 42 45 483 559 640 0 0 0 0 35 0 15 0 15 555 616 700 1 0 2 0 0 2 6 3 5 1 1 2 87 83 104 258 343 365 146 172 190 1 4 10 1 2 10 0 0 10 Unknown 54 8 Total 1 555 616 700 PROGRAM INFORMATION 1/23/2018 3:44:19 PM Page 15 of 21 DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 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 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 Weekend Meal Backpack Program 1. Program Activity Name Feeding hungry kids Program Goal Partner with local schools, after school centers, non - profits, Town Housing Departments, etc. to provide food weekly to local kids through our Weekend Meal Backpack Program. Performance Measures TABLE maintains a Current Numbers Sheet of children we serve every single week. We will use this to determine how many kids are served. Previous Year Program Results Provided up to 555 kids with healthy food for 34 weeks of the school year. Current Year Estimated Results Provide up to 625 kids with healthy food for 34 weeks of the school ear. Next Year Projected Results Provide up to 700 kids with healthy food for 34 weeks of the school year. 2. Program Activity Name Help kids succeed Program Goal Provide nutritious foods that kids need every week as well as reinforce health and academic habits using our Food for Thought Worksheets (academic and nutrition education worksheets that go home monthly with our kids). Performance Measures TABLE executes surveys every spring with parents of children that TABLE serves. Previous Year Program Results 51% of kids experience at least one additional benefit (some other academic, health, nutritional, personal, physical, or social benefit as a result of receiving the nutrition they need every week. • Children always tried new food 38% of the time before receiving healthy food from TABLE. After receiving weekly food from TABLE, children always tried new foods 62% of the time (24% more). • Children always ate healthy foods 59% of the time compared to 74% after participating in TABLE's WMBP 16% more). PROGRAM INFORMATION 1/23/2018 3:44:19 PM P a g e 16 of 2 1 DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION PROGRAM INFORMATION 1/23/2018 3:44:19 PM • 41% of children were eating junk food all the time before receiving food from TABLE compared to 26% after participating in the WMBP (15% more). • We also saw a 12% increase in children getting above average grades after participating in TABLE's WMBP for more than one year. Current Year Estimated Results A 3 -5% increase across all of the above listed categories, meaning: • 54% of kids experience at least one additional benefit • Children try new foods 27% more. • Children eat healthy foods 19% of the time. • Children eat junk food 18% less. A 15% increase above average grades. Next Year Projected Results A 3 -5% increase across all of the above listed categories, meaning: • 57% of kids experience at least one additional benefit • Children try new foods 30% more. • Children eat healthy foods 22% of the time. • Children eat junk food 21 % less. • An 18% increase above averse grades. 3. Program Activity Name Develop relationships with families Program Goal TABLE seeks to develop relationships with a small, but diverse group of families we serve in order to create meaningful interactions and determine the direction of our current and future programs. Performance Measures We will evaluate the degree in which we achieve stated goals by measuring the number of annual interactions we have and the number of families we interact with. Previous Year Program Results N/A Current Year Estimated Results 2 annual interactions with 10 families. Next Year Projected Results 3 annual interactions with 15 families. PROGRAM INFORMATION 1/23/2018 3:44:19 PM DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION p) Program Budget 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 • 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. 3. This program budget represents what percent of the agency budget? 84% 4. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. PROGRAM INFORMATION 1/23/2018 3:44:19 PM Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Total Cost of Program $409,482 $477,278 $574,936 Total # of Individuals 555+ kids /weekly 625+ kids /weekly 700+ kids /weekly Cost Per Individual $737.81 $763.64 $821.34 PROGRAM INFORMATION 1/23/2018 3:44:19 PM DocuSign Envelope ID: 2AC82140-8F6C-4125-8743-OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION TABLE Ministries, Inc. Agency Budget September 1, 2016 - August 31, 2019 Ordinary Income /Expense Income Grants Government Grants Carrboro HS Chapel Hill HS Orange County HS Private Foundation Grants Total Grants Gifts in Kind - Goods Individual Donations Corporations & Matching Gifts Rebate cash, gift cards Local Bus, Clubs, Orgs, Events Religious Organizations UNC Groups and Events Foundations and Trusts Program Generated Revenue Special Events Total Income Gross Profit Expense Food, Supplies & Equipment Weekend Meal Backpack Program Summer TABLE Program SnackChef Alternative Sites TABLE On the Go Total Food, Supplies & Equipment Payroll Expenses Compensation Executive Director Salary Program Director Program Associate Community Outreach Coord. Project Specialist PR Director Program Assistant Total Compensation Payroll Taxes Total Payroll Expenses Budget 2016 -2017 2017 -2018 2018 -2019 5,000 9,000 15,000 4,000 4,500 15,000 5,000 8,500 15,000 40,000 39,582 25,819 54,000 61,582 70,819 172,499 204,650 241,487 167,756 179,644 204,067 4,604 3,063 3,676 585 83 584 32,678 41,890 47,984 19,289 37,137 43,821 435 7,090 7,941 48,500 38,962 46,754 0 0 0 21,0041 39,082 42,828 521,351 613,183 709,960 521,351 613,183 709,960 166,311 231,848 258,987 59,543 58,939 73,111 5,823 8,550 13,791 12,900 5,760 5,760 7081 2,000 3,000 245,285 307,097 354,649 48,174 53,000 55,650 35,496 38,020 39,921 29,000 30,450 31,973 14,877 0 0.00 10,286 11,338 11,905 1,360 16,320 17,136 0 0 30,000 139,192 149,128 186,584 11,458 13,7201 17,166 150,6501 162,848 203,750 DocuSign Envelope ID: 2AC82140-8F6C-4125-8743-OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Rent and Utilities (Rent, Utilities, Building Maintenance, Moving) 50,222 44,483 54,724 Other Employee - Related Expenses (Training, Reviews, Workers' Comp, Travel) 2,104 6,607 6,805 Other Expenses Contract and Professional Svcs (CPA, Accounting, Marketing) 11,344 27,647 29,030 Development and Fundraising 5,543 8,876 9,764 Office Expenses (Fees, Office Supplies, Postage, Printing, Etc.) 11,884 12,264 12,632 Information Technology 3,600 5,648 5,818 Vehicle Expenses (Registration, Maintenance, Insurance, Fuel) 1,470 1,570 1,617 Operations (Liability Insurance, Depreciation, Meetings, Inventory Adjustment, Etc.) 3,568 3,461 3,565 Total Other Expenses 37,409 59,468 62,426 Total Expense 485,670 580,502 682,354 Net Ordinary Income 35,681 32,681 27,606 Net Income 1 35,6811 32,681 27,606 Comments: 1. TABLE's total income in 2016 -2017 totals $521,351. More than $172,000 of these funds come in the form of food. Our actual cash totals con For this reason, we did not obtain an audit for our 2016/17 fiscal year. We have plans to obtain an audit on our current fiscal year. 2. Contract Services more increase significantly in 2017 -18 because we replaced our full -time Community Outreach Coordinator with a part-tim will be moved to employee status in FY 2018 -19. Her responsibilities involve raising funds, educating the community about childhood hunger /T, planning, etc. DocuSign Envelope ID: 2AC82140-8F6C-4125-8743-OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION TABLE Ministries, Inc. Program Budget September 1, 2016 - August 31, 2019 Ordinary Income /Expense Income Grants Government Grants Carrboro HS Chapel Hill HS Orange County HS Private Foundation Grants Total Grants Gifts in Kind - Goods Individual Donations Corporations & Matching Gifts Rebate cash, gift cards Local Bus, Clubs, Orgs, Events Religious Organizations UNC Groups and Events Foundations and Trusts Program Generated Revenue Special Events Total Income Gross Profit Expense Food, Supplies & Equipment Weekend Meal Backpack Program Summer TABLE Program SnackChef Alternative Sites TABLE On the Go Total Food, Supplies & Equipment Payroll Expenses Compensation Executive Director Salary Program Director Program Associate Community Outreach Coord. Project Specialist PR Director Program Assistant Total Compensation Payroll Taxes Total Payroll Expenses Budget 2016 -2017 2017 -2018 2018 -2019 5,000 9,000 15,000 4,000 4,500 15,000 5,000 8,500 15,000 40,000 39,582 25,819 54,000 61,582 70,819 172,499 204,650 241,487 167,756 179,644 204,067 4,604 3,063 3,676 585 83 584 32,678 41,890 47,984 19,289 37,137 43,821 435 7,090 7,941 48,500 38,962 46,754 0 0 0 21,0041 39,082 42,828 521,351 613,183 709,960 521,351 613,183 709,960 166,311 231,848 258,987 59,543 58,939 73,111 5,823 8,550 13,791 12,900 5,760 5,760 7081 2,000 3,000 245,285 307,097 354,649 24,087 26,500 27,825 35,496 38,020 39,921 29,000 30,450 31,973 7,438 0 0 2,571 2,835 2,976 680 8,160 8,568 0 0 30,000 99,272 105,965 141,263 8,135 9,7411 12,875 107,4081 115, 706 154,137 DocuSign Envelope ID: 2AC82140-8F6C-4125-8743-OB8594E61466 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Rent and Utilities (Rent, Utilities, Building Maintenance, Moving) 45,200 40,035 49,252 Other Employee - Related Expenses (Training, Reviews, Workers' Comp, Travel) 526 1,652 1,701 Other Expenses Contract and Professional Svcs (CPA, Accounting, Marketing) 0 0 0 Development and Fundraising 0 0 0 Office Expenses (Fees, Office Supplies, Postage, Printing, Etc.) 4,754 4,906 5,053 Information Technology 2,700 4,236 6,389 Vehicle Expenses (Registration, Maintenance, Insurance, Fuel) 1,470 1,570 1,617 Operations (Liability Insurance, Depreciation, Meetings, Inventory Adjustment, Etc.) 2,141 2,077 2,139 Total Other Expenses 11,064 12,789 15,197 Total Expense 409,482 477,278 574,936 Net Ordinary Income 111,868 135,905 135,024 Net Income 111,868 135,905 135,024 DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 EXHIBIT `B" Scope of Services — FY 2018 -19 Outside Agency Performance Agreement Agency Name: TABLE Ministries, Inc. Program Name: Weekend Meal Backpack Program Funding Award: $10,450 Outline how the agency will spend Orange County's funding award. Expense Description Amount Food $6,270 Program Staff Support $2,090 Rent $2,090 TABLE executes surveys every spring with parents of A 3% increase in benefits kids experience children that TABLE serves. as a result of participating in our hunger - relief programs. This means that 57% of Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2019. • Deliver healthy food every week to Chapel Hill- Carrboro kids Engage with the families we serve by providing volunteer opportunities, reaching out by email, providing our contact information for feedback and questions, and developing deeper relationships with our families. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons /units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results TABLE maintains a Current Numbers Sheet of Feed 700 kids for 34 weeks children we serve every single week. We will use this to determine how many kids are served. TABLE executes surveys every spring with parents of A 3% increase in benefits kids experience children that TABLE serves. as a result of participating in our hunger - relief programs. This means that 57% of our 700 kids experience one additional benefit: improved grades, healthier eating habits, try new food more frequently, increase in above average grades, etc. We will evaluate the degree in which we achieve stated 3 annual interactions with 15 families goals by measuring the number of annual interactions we have and thi D..c Signed by:- ,-s we interact with. L sbjtw -[ iffiKIS OF9MEFC1A6141A... Certified by: (Provider's Si e) Executive Director 8/16/2018 Title: Executive Director Date: 7/27/18 DocuSign Envelope ID: 2AC82140 -8F6C- 4125 - 8743- OB8594E61466 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. Certified by: F Docu5igned by: 6k, -rt ff tn,s Executive Director 8/16/2018 OF9MEFC1A6141A... Title: Date: (Provider's Signature) (TABLE) Orange County Outside Agency Performance Agreement Page 9 of 9 Rev. 7118 DocuSign Envelope ID: 2AC82140-8F6C-4125-8743-OB8594E61466 TABLMIN -01 SHURLEY .14C"R" CERTIFICATE OF LIABILITY INSURANCE �f. DATE(MMIDDIYYYY) 07/12/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE 781 -0200 FAx (A/C, No, Ext): ( 919 ) (A/C, No): (919) 582 -1999 Raleigh / Assured Partners of North Carolina, LLC 4505 Falls of Neuse Road, Suite 350 Raleigh, NC 27609 ADDRESS: INSURERS AFFORDING COVERAGE NAIC # 07/09/2019 INSURER A: Cincinnati Casualty Company 28665 INSURED INSURER B: INSURER C: $ 10,000 Table Ministries Inc INSURER D: PERSONAL& ADV INJURY 209 E Main St Carrboro, NC 27510 INSURER E AGGREGATE LIMIT APPLIES PER: JECT PRO - POLICY 1:1 PRO- 1:1 LOC OTHER: INSURER F: $ 2,000,000 PRODUCTS - COMP /OP AGG 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 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR ETD0496055 07/0912018 07/09/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ MED EXP (Any one person) $ 10,000 PERSONAL& ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: JECT PRO - POLICY 1:1 PRO- 1:1 LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY (CO, M BINED SINGLE LIMIT E accident $ BODILY INJURY Per person) $ BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PROPRIETOR ANY OFFICER /MEM ER/EXCLUDED? ECUTIVE ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A A Property Sexual Abuse Cov. ETD0496055 ETD0496055 07/09/2018 07/09/2018 07/09/2019 07/09/2019 Contents Aggregate 25,000 2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Orange Count 9 y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE, ACORD 25 (2016/03) ©1988 -2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD