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HomeMy WebLinkAbout2018-550-E DSS - OCIM outside agency agreementDocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the fast 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 Orange Congregations in Mission, a not - for - profit corporation, located at 300 Millstone Drive, Hillsborough, NC 27278 ( "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 Provider 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 to the residents of Orange County, as outlined in the Outside Agency Funding Application and any amendments or revision thereto (Exhibit "A") and Emergency Assistance Scope of Work ( "Exhibit B "), both of which are attached and hereby incorporated into this document as if set out herein. The Scope of Services in Exhibit A 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 C. 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 hands for the provision of services described in Exhibit A, Scope of Services, and more particularly described in the Program Budget or Revised Program Budget, the maximum sum of Eighty Four Thousand, Nine Hundred Eighty Two Dollars ($84;982). The County also agrees to appropriate funds for the provision of services described in Exhibit B, the maximum sum of Fifty One Thousand Dollars ($51,000). The total amounted appropriated by the County to Provider for these services shall be One Hundred Thiry Five Thousand, Nine Hundred and Eighty Two Dollars ($135,982). b. All funds appropriated shall be used for purposes described in Exhibit A and Exhibit B. 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 provided in Exhibits A and B, at the discretion of the County the Provider may be required to repay the funds to the County. c. Funds Appropriated for Outside Agency Funding (Exhibit A) Services. Orange Congregations in Mission Orange County Outside Agency Performance Agreement Revised 612018 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC i. For funds appropriated for Exhibit A services, the Provider shall be paid in four equal installments in the amount of $21,245.50. 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. ii. 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. iii. Once Provider has satisfied its obligations as provided in c.l. above 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. d. Funds Appropriated for Emergency Assistance (Exhibit B) Services. L For funds appropriated for Exhibit B services, the County will reimburse Provider for services described in Exhibit B up to the limits allocated by this Agreement. Provider shall only be reimbursed for actual expenditures for approved services. ii. For reimbursement, Provider must submit copies of bills, checks, receipts and/or other proof of expenditures to the person designated by the County. Reimbursement will be provided bimonthly. iii. For reimbursement of staff costs, Provider shall submit the payment records for staff cost. The County will reimburse the Provider monthly upon receipt of a complete and correctly filed report. e. 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 treasures 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 15, and July 8 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: L 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 2 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 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 (I0) 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. 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 3 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 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 $500,404 each accident, disease policy limit and disease each employee $1,000,040 Each Occurrence $2,040,000 Aggregate $540,004 Combined Single Limit $1,040,040 Each Occurrence $2,000,040 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. 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. S. 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. Id. 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 4 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 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 Provider provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last /mown 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: County: Nancy Coston Orange County Department of Social Services Post Office Box 8181 Hillsborough, North Carolina 27278 Provider: Executive Director Orange Congregations in Mission 300 Millstone Drive Hillsborough, North Carolina 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. Severabiiity. 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 Iaws 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. 18. 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. S DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti- discrimination laws, policies, rules, and regulations and the Orange County Non - Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http : / /www.orangecountyne.gov/ departments / purchasing _division /contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. 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. 19. 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 I A 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. OacuSigned by: . � �c al'`m& S . vt t,Gaan.d� BE &2EM675A493... Rev. Sharon S. Vreeland, Executive Director " oocu5igned b;: uge County Government 0637994B755E477... Bonnie Hammersley, County Manager 9/7/2018 9/10/2018 Date Date R DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC Exhibit A Outside Agency Application and Scope of Services DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Orange Congregations in Mission Inc. Applicant Organizations Physical Address: 300 Millstone Dr. Hillsborough, NC 27278 Applicant Organization's Mailing Address: 300 Millstone Dr. Hillsborough,_ NC Applicant Organization's Web Address: www.ocimnc.org Executive Director: Rev. Sharon S. Freeland Telephone Number.- 919 - 732 -6194 ex. 10 Tax ID Number.-.58-1563438 E -Mail: ocimexecdir(W-embargmail.com lb) 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 Cheri Or� ang _ - HS Hill - HS Count3 Ex. Youth Afterschool Program $10,000 $15,000 $5,000 ARerschool Program Coordinator salary and materials for youth activities and projects — - _._- Samaritan Relief Ministry Food for pantry, rent and utility assistance for recipients. salary fornrooram manager. Totals $30,000 58,415 1 58,415 - - -- 58,415 c) To the best of my knowledge and relief 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: l A - Executive Director Date Signature: J2-j 1113bg Bard Chairperson Date AGENCY INFORMATION 112312018 12:19_•10 PM Page 8 or 25 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 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 F] x a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel l --fill, or Orange County? 0 x 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? 0 x c) Current beneficiaries of the program for which funds are being requested? x 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 identitylexpression, 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 Change 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 anv arant awarded. Signature: E e utive Director Date Signature. Boa d Chairperson Dal AGENCY INFORMATION 112312018 8:43:34 AM Page 10 of 25 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, 9981 - present Date of Incorporation (MonthlYear): 0511981 b) Agency's Purpose /Mission (no more than a few sentences): Mission Statement: To minister to the urgent needs of citizens of northern Orange County through the volunteer efforts of diverse congregations and individuals inspired by faith in God, and to enhance self- sufficiency and awareness of community resources. c) Types of Services the Agency Provides (bullet format): - Samaritan Relief Ministry. Provides emergency food, and utility, housing and medication payment to those members of the community in financial crisis. - Meals on Wheels.: Provides a daily, home delivered meal to those who are homebound and are unable to provide lunch for themselves. - Thrift Shop: A place to donate gently used clothing, books, and household items which in turn are sold at a low cost. The revenue supports OCIM's programs. d) Agency's History with Providing These Services: After 36 years, OC1M continues to serve the northern Orange County population. With the help of a supportive community and dedicated volunteers, 01CM has maintained a reputation of quick and compassionate responses to the human needs in Orange County. e) Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director? Are there new initiatives ?) f) Schedule of Positions (For Entire Agency) • Full Time Equivalent (FTE) staff will be noted as 1.00; half time as .50; quarter time as .25, etc. • Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours = Volunteer FTE 2,080 # of FTE - Full -Time Paid Positions: 4 # of FTE - Paid Part -Time Positions: 2.5 # of Volunteers: 980 # of FTE - Volunteers:6 Arronrti lnfnrrnnfinrn 919.,w9n1R 99•9n-in PAR P:a ri n 1 it e) f 7 Z; DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC g) Lining Wage Does this agency pay permanent employees a minimum living wage? (Yes ]No) yes If yes, is this agency an Orange County Living Wage Certified Employer? no If no, please explain. We have not submitted an application Ary.onr -v 1nfnrrr=Knn 717.1419nIR 79 °9f)-1n PAA P'-1 n n 1 9 o f 7 in DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC Updated with December 2017 numbers. Actual 2017 Estimated 2018 Pending 2019 112,282 128,879 128,879 207,234 248,419 248,419 71,415 71,415 71,415 4,681 5,600 5,600 wernment Grants ierBY 100,121 112,308 112,308 8,879 8,879 8,879 vidends, investment 4,109 4,500 4,500 354,216 330,000 330,000 862,937 2017 910,000 2018 910,000 2019 327,753 409,829 4091,829 104,032 35,531 35,531 4,483 4,000 4,000 2,500 7,000 7,000 92,918 354,216 111,120 330,000 111,120 330,000 12,752 12,520 12,520 898,6531 1 910,0001 910,000 DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC h) Agency Budget i. Is your agency currently receiving and/or requesting other (non - Human. Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (YeslNo) No If yes, please list below: Include aH programs that have funding requestslawards/totals from Carrboro Chapel Hill and Qmgge Counh► governments (other than Human Services). DO NOT include federal funding sources, such as GDBG and HOME. Program FY1748 Award FY18 -19 Request Source Ex. Affordable Rental Rehabilitation 0 $20,000 Carrboro - Affordable Housing Ex- Agency Administration $75,000 $75,000 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 x!s 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 o Private Donations o Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel /-fill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) ❑rwnril Whrmatinn 717'41an1R R•a .q =u ASIA p p ri n 1 1 o f 9 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government Federal Government (CDBG /HOMEIetc.) Private Foundation Grants o Other Revenue a 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 Please provide a brief explanation for Surplus or Deficit, and significant changes. Financial contributions are down agency -wide. Some of our foundations have changed their focus from human services to areas such as the environment and social justice; only half of the anticipated FEMAIEFSP allocation was received in November 2097, the remainder is pending; the Triangle United Way allocation was cut by 75% in July 2097. Perhaps due to the numerous natural disasters happening in other parts of the country, donors are choosing to make their charitable donations to these disasters instead of keeping their finances local. iv. What is your agency's fiscal year? 11912098 through 9213112018 (Example: July 9, 2016 through June 30, 2097) Ano!�nr►l InfnrMptinn '#I?.w9niR T -717•.47 PAR P q" A 9 A o f 7 9 DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC 3. PROGRAM INFORMATION (submit a separate Section 3 for each program) Program Name: Samaritan Relief Ministry Program Primary Contact and Title: Kay Stagner, Manager of Client Services Telephone Number. 919 - 732 -6194 ext. 12 E -Mail: ocimsrm@embaMmaii.com 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 afierschool 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 - Neigh b o rh o o dsMesiden is Affordable Housing Affordable Healthcare -- Education Family Resources JobslJobs Training Food Transportation x x x x x Other. Financial assistance for rent, utility, prescription medication x x x x x c) Provide a bulleted list of other agencies, if any, with which your agency coordinatesl'collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinatedTcollaborative efforts. • Orange County Department of Social Services: The Samaritan Relief Ministry receives referrals for individuals and families needing food and emergency financial assistance_ • Orange County Health Department: "WIC" and other matemitylyoung children related programs make referrals for food, baby formula, and diapers. • Lutheran Family Services and other mental health case management programs: social workers and case managers refer clients to the Samaritan Relief Ministry for food. PPr)r RA AA IAIP r -?AAA TinN ❑ AA p a" ra 'I C; n f 7J; DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC O Orange County Schools: Social workers refer students and their families for food. O Private and Charter Schools: These schools are becoming more active in collecting food for the pantry. O Area Congregations: Pastors of OCIM member congregations make referrals for food and financial support for people within these congregations. Food referrals are available to people who are initially unaware of Orange County Department of Social Services and choose to go to churches for help. Many donations to the Samaritan Relief Ministry food pantry come through monthly food collections as well as general donations to the Samaritan Relief Ministry. Many of the Samaritan Relief Ministry volunteers come from member congregations. O Orange County Sheriff's Office: The Sheriffs Office held a fan drive this summer and OCIM received many fans to distribute to people in need. ® Food Bank of Central and Eastern NC: The Samaritan Relief Ministry receives food at low or no cost. v PORCH Chapel Hill & Hillsborough: The Samaritan Relief Ministry pantry receives monthly donations of non - perishable food items from local neighborhoods. 0 Food Lion Stores: Local Food Lion stores donate `pulled" or "near date" produce, meat and bakery goods. They also provide food through the sale of their "Holiday's without Hunger" boxes. ® Weaver Street Market: Through special fundraising campaigns, the pantry receives weekly deliveries of fresh eggs, produce, butter and cheese. Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town /County priority /goal? The Samaritan Relief Ministry provides groceries and financial assistance for rent, utilities, and prescription medication for families and individuals living in northern Orange County. This program aligns with Orange County's Coal 1: ,Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well -being of all county residents. e] Describe the community need or problem to be addressed in relation to the Chapel F;i {! Human Services !Needs Assessment, Orange Counbl BOCC Goals and Priorities, Town of Chapel l ill Council Goals, _Carrhoro_ Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, Le. Chapel Hill Human Services Needs Assessment) to support the need for this program. The Samaritan Relief Ministry provides food and emergency financial assistance (rent, utilities, pharmacy) for people living in northern Orange County. Over the years, as the community has grown, the need For emergency assistance has grown. For historical perspective, in 1980, there were 94,232 people living in Orange PpnrrrAnn rKIF:nunnATinnr 1/9.7/9018 R•QR-4.d AAA P -, ; DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC County. That year the Samaritan Relief Ministry assisted 4,327 individuals, 3009 of those were assisted with food; In 2015, there were an estimated 140,144 people living in Orange County_ The Samaritan Relief Ministry assisted 10, 775 individuals, 9,407 of those were assisted with food. For families and individuals living in northern Orange County, the OCIM food pantry is the primary place to receive emergency food. The financial assistance that is available to help with rent, utilities, and prescription medication is often one part of the package" to help people stay in their homes and keep basic utilities available. Because the Samaritan Relief Ministry requires referrals from the Orange County Department of Social Services for financial assistance, the social workers can count on OCIM to be one piece in helping clients get large bills paid or to be available when all public funds have been exhausted. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The Samaritan Relief Ministry provides services to people living within the geographical boundaries of the Orange County School District. This area is primarily rural, with Hillsborough being the largest municipality. The Chapel Hill /Carrboro area is served by the Inter -Faith Council for Social Services- The Samaritan Relief Ministry is a referral -based program. Various Orange County departments, school social workers, pastors, mental health programs, and local non - profits make referrals for their clients who are in need of the services this program offers. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Kay Stagner is the Client Services Manager, she has managed the Samaritan Relief Ministry for over 20 years. flay is from the northem Orange County community and is knowledgeable of the community and its resources. When the program manager has to be out of the office, the Meals on Wheels Coordinator "who shares office space) and volunteers answer the office phone and receive referrals. They are trained by the program manager over a period of several weeks. There is a reference file they can refer to if there are questions_ Food pantry volunteers are given an orientation and shadow an experienced volunteer until they are able to work independently. All volunteers have had references checked and a Confidentiality Statement signed prior to beginning volunteer duties. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. The Samaritan Relief Ministry is open year - round, Monday- Friday, 9.00 a.m. -5:00 p.m -; households are able to receive food from the pantry a total of seven times during a 12- month period. As long as a request is not made twice in one week, the time between food referrals does not matter. Financial assistance has a maximum amount (usually $75 -$100) available every six months. PRO r_R,4All IAIWnPA44TinAi AnrJ P:4 n a 1 7 n f _; DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 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) In a healthy and caring community, people should not be hungry because they are unable to afford food. They should not have to have utilities shut off because they had to pay for car repairs so they could continue to get to work. People should not be evicted from their home because they lost their job and have not been able to find another one soon enough to pay rent. The Samaritan Relief Ministry cannot help all people with all of their financial needs, but we can partner with Orange County in helping the most financially fragile members of our community. Food and financial donations come to the Samaritan Relief Ministry by community members who care deeply about the quality of the community they live in. OCIM is the conduit by which the members of the community with plenty share with those without. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If the Samaritan Relief Ministry did not receive funding from Orange County, fresh milk and meat purchases would be greatly reduced and during the summer and fall when donations are low, additional non - perishable food could not be purchased, 85 households would not receive help with rent and utilities and the program manager would have to either have a cut in pay or funds would have to be diverted from other areas to pick up the balance. k) What percentage of your target population is low - moderate income? 1 00 1) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc.?) The Samaritan Relief Ministry does not currently have a formal evaluation process, but there is a comment box available. The comments all express great appreciation for the assistance and the kindness shown through this program- "OCIM means the difference in whether or not my children get to eat dinner some nights. It means whether two very smart, caring kids go to bed hungry. With OCIM's help, my children have a better chance of changing the world. "E. B. "OCIM is a true blessing. My husband passed away 3 years ago and it has been a struggle getting bills paid and having food. OCIM has helped my family numerous times, and we thank you so much!" J. C- m) Include any other pertinent information. In the demographics chart on the next page, please note that the Ethnicity area is based on households not individuals. In the Geographic Location area, the locations are based on addresses. Those listed as being in the Town of Hillsborough may not live within the city limits, but they do get their mail through the Hillsborough Post Office. Ppn( -.PAAA IAIPr 1PMATIr),AI R•Q.q•111 4A4 F) ;Q n f 9 ; DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC 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 Actual Estimated Projected 2017 1 2018 2019 Gender INDIVIDUALS Male Female Total Ethnicity HOUSEHOLDS African-American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other: specify Latino /unknown Total Of the above, how many Hispanic/Latino Of the above, how many non- Hispanic/Latino Total Age INDIVIDUALS 0 -5 years 6 -18 years 19 -64 years 65+ years Total Geographic Location INDIVIDUALS Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non- Public Housing) Town of Carrhoro Town of Hillsborough City of Mebane (Orange County) Change County (Outside Municipalities) 4,172 4,231 4,300 5,469 5,610 5,700 9,641 9,841 10,000 1,303 1329 1350 3,200 3273 3326 3,379 3,453 3,508 1,889 1930 1961 1, 5015 1535 1560 187 190 197 3,379 3,453 3,508 179 980 182 3,200 3273 3326 3,379 3,453 3,508 1,132 2,572 1151 - 2617 5786 _ 1170 2660 5,677 5880 260 287 290 1 9,641 1 9,841 1 10.0001 Total 9,641 9,841 1 10,0001 PRnr,RAAA 1A1 nRAAAT10Al AAJ A a rr ,�a I a o f a 5,706 5816 5910 1, 5015 1535 1560 2,430 2490 2530 Total 9,641 9,841 1 10,0001 PRnr,RAAA 1A1 nRAAAT10Al AAJ A a rr ,�a I a o f a DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 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 7 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time- bound. Click on SMART Goals to team more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderlyldisabled 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: Samaritan Relief Ministry 1. Program Activity Name Provide emergency groceries to food insecure households Program Goal Provide a week's worth of groceries to referred households a maximum of seven times in 12 months. Performance Measures Track the number of times individual households receive food through Access database. Produce monthly report of total number of individuals receiving assistance. _ Previous Year Program Results 8,872 individuals 3,169 households) received fond in 2017. Current Year Estimated Results 9,000 individuals (- 3,214 households) will receive food in 2018 Newt Year Projected Results 9,100 individuals ("3,250 households) will receive food in 2019 2. Program Activity Name Provide emergency financial assistance for rent and utilities Program Goal 130 households will receive emergency financial assistance to be able to retain housing and utilities. _ Track the amount of financial assistance individual households receive through Access database. Produce monthly report of total amount of financial assistance given. Performance Measures Previous Year Program Results 238 households received emergency financial assistance for rent and utilities in 2017. Current Year Estimated Results 242 households will receive emergency financial assistance for rent and utilities in 2018 Next Year Projected Results _ 246 households will receive emergency financial assistance for rent and utilities in 2019. 3. Program Activity Name Program Goal Performance Measures Previous Year Program Results — Current Year Estimated Results Next Year Projected Results PPr)r, PAhA inlFr)PA 4 TinAi 719qI9n1 R .Q-A 4 -.Qd Am DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC 0 cn cn C= to C O 4� m 40 .C_ V u tko SO LA L- N E C i� c-i C] N t- D L IM ++ IW a[1 'O 7 03 E La i]1! f1.. W III LL1 E cn Q N 4a %J ©o O N aJ m E LU LU P% C] N 16 3 a.r v d LU z LU LU W ac a o LA 0 r• CD CD Ln C7 IT ri as ri n C7 0 m C) �[ O C3 ci G m C] N C7 w 00 Vq H Ln 6 C? N 6 OQ to Ln �* w to a Ca n 00 C] m Lr C V) V) C? 00 Lr1 rl 06 tri tri d' M C7 rl or N LO C] N 6 C7 G1 m r1 U l m `i r• V-4 co m m 4 0 o to o n v o Ln Ca t *4 00 T+ C7 n a O ® ri 0 o s-+ C;) en CD Lv CD w 00 �f I-i to o C) r4 CD 00 V) tri cr w UD CD a r• c0 0 m ul C] Ln Ln n c4 W -mr 06 Lr` Vx rri Ci P N u7 C] of C7 6 Gf m r I Ln m r i r► r t 00 co CA oo r- Ln ri -e C7 v to co P% rti L n .-A Lti M TT- LD Rr Ca to -4 00 N [t m sV .-1 m TA CD m d r I � c t G1 to r• d� LO C7 t r-! f U N O Lrl nl Cn . 1 lt? tV r► cT 1p t- ti 00 d' rw l eF' tfy N C] M +� r- C' r: N c-1 m m m OQ f� N to V) 0 C U' C [17 L- to W Nw tn U'' L > z fm = QF C p! Ri 4A $ 7 7 f+ LU '� m w Lam.. E H aOa (] ! QJ CL CL 0 .S: L fG LA Cr O (✓ 0 E ca M LU a L D IYy iI1 " u 0�1 Vf � (� w (,4 "a 0 - � O � H 0a a- L] 0 7 7 C w'1 cU S7 ' -O t Ci j Qy u luu O CL M W tL OL d ❑ ❑ ❑ ❑ l fL- u ❑ 1^ F © DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC p) Program Budget `� R M 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 a Program Generated Revenue o ,Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) o tither Govemment Grants • Triangle United Way • State Government • Federal Government (CDBG /HOME/etc.) • Private Foundation Grants a Other Revenue Expenditures a Compensation o Rent & Utilities a Supplies & Equipment o Travel & Training a Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. 3- Miscellaneous /father Income includes interest, recycling revenue, dividend and investment 4. This program budget represents what percent of the agency budget? .57% 5. COST PER INDIVIDUAL This Cast per Individual must reflect the total program budget divided by the total number of program individuals in this application. PRnrRAAA WF:nPAAATtnnr 919119nl R 9- 9rt -dR PAA P P r, n 99 r, ?, 9 , Actual 2016 -17 Estimated 2017 -18 Projected 2018 -19 Total Cost of Program 507,794 499,881 499,881 Total # of Individuals _ 9,641 9,841 9,841 Cost Per Individual _ 52.67 1 50.84 50.80 PRnrRAAA WF:nPAAATtnnr 919119nl R 9- 9rt -dR PAA P P r, n 99 r, ?, 9 , DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 'I. GONER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Orange Congregations in Mission Inc Applicant Organization's Physical Address: 300 Millstone Dr. Hillsborough, NC 27278 Applicant Organization's Mailing ,Address: 300 Millstone Dr. Hillsborough,_ NC 2 72 78 Applicant Organization's Web Address: www.ocimnc.orq Executive Director. Rev. Sharon S. Freeland Telephone Number. • 919 -732 -6194 ext. 10 Tax ID Number. 58- 1563438 E -Mail: ocimexecdi §embargmail. com b) f=unding 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 - Ex. Youth Atierschool Program - - - - Af#erschooi Program Coordinator salary and materials for youth activities and projects Carrbaro Clrapei Hill - HS Orange Cohn -HS Total $30,000 - HS $10,000 15,000 $5,01010 Meals on Wheels - Catered meals for Meals on Wheels and a part -time employee to assist with distributing meals to the rural parts of Orange County 34,000 34,000 Totals 34,000 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. F Signature; ( ) { Executive {director Date c i. Signature: �� &3 Board Chairperson Date AGENCY INFORMATION 112312018 12:17:33 PM Page 3 of 25 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 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 x aj Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ x 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? [❑ x cl Current beneficiaries of the program for which funds are being requested? ❑ x dj 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 identify /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: f. K"' �n Iwo 1 f 2 IS/ Ex cutive Director ,date Signature: �to Board Chairperson Date AGENCY INFORMATION 112312018 8:54 :00 AM i} a J c 1 0 o f 2 5 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS); a) Years in Operation, 1981-present Date of Incorporation (MonthlYear): 0511981 b) Agency's Purpose /Mission (no more than a few sentences): To minister to the urgent needs of citizens of northern Orange County through the volunteer efforts of diverse congregations and individuals inspired by faith in God, and to enhance self - sufficiency and awareness of community resources. c) Types of Services the Agency Provides (bullet format): a Meals on Wheels: Provides a nutritious meal, Monday through Friday to primarily elderly people who are homebound, alone during lunchtime, and unable to prepare a nutritious meal themselves due to either cognitive or physical disability. ® Samaritan Belief Ministry: ,Provides emergency food, utility and rental payment, and prescription medication payment. @ Thrift Shop: A place where clothing, books, and household items can be purchased for very low cost and donors are able to make tax deductable donations_ d) Agency's history with Providing These Services: OCIM's Meals on Wheels program began in September of 1981. At that time the program was strictly volunteer run_ In October 2001, OC1M hired the first part -time Meals on Wheels Coordinator. The current Meals on Wheels Coordinator has been with the ,program for 12 years. The Samaritan Relief Ministry, originally called the OCIM loan program, Megan with a check book that was kept by the secretary at the First Baptist Church in Hillsborough_ The food pantry and Samaritan Relief Ministry office opened in the mid- 1980's. The current program manager has been with the program for 20 years. The current Executive Director has been with OC1M for 27 years. 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 ?) iJnPnr it lnfnrmatinn 1/gi/9n ?R P-?s .no ,4m P 'n rip 1 1 r3 r 9 N DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC Q Schedule of Positions (Far Entire Agency) Full Time Equivalent (FTE) staff will be noted as 1 -00, half time as .50,• quarter time as .25, etc. Calculate a Full Time Equivalent for all recorded volunteer hours using the following: Total Volunteer Hours != Volunteer FTE 2,080 # of FTE - Full-Time Paid Positions: 4 # of FTE - Paid Part Time Positions: 2.50 # of Volunteers: 180 g) Living Wage # of FTE - Volunteers:6 Does this agency pay permanent employees a minimum living wag ? (Yes / No) Yes If yes, is this agency an Orange County Living Wage Certified Emptoyer? no If no, please explain. We have not submitted an application. An+pnr•~r 1nfnrmatinn 117.117f l q R•5d-nn AAA P .-i rr n 1 9 n f 7 ri DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC (6 .sa ra 7 m to C to C N:. r-1 O N Q7 U LLI N d) 0 u L.a {U a a� s� 0 N E 4a U dl v Q V1 F tn L7 4w ro CD bA b0 bO u ca to U C C v C? 4 C [SS L9 Y G Q,} P C L i q 0 0 LD fEt CU tto Z >���� cs° f°LL' E C cu c di S C LLu � :3 ■- LL Ln w LL C 0 C 0 ca z w CD E C L9 dl u1 �p "0 0 W C @ Ln W L � Q +, 2 oC a a 0 w a� L6 tia u C M 0 G C W a) u 0 Q d7 Lr, N U co L ¢ � 'V LU LIL y ry N Eiy 11 LU (u m E La D- U D� iu U 0 Ln L fL 0) r- 00 Lm!] d CT t-I 11 C N Ln r i d is 0 C3 LD �} 00 0 m (n r- 00 00 O C7 Ln O 0 G7 ch r-I O oo N N Liz lD I- d' rn Ln Ln 0 C7 0 O �`" 0 C-4 ct ct ri a ri N C 4 G Qt eM'1 0 O O 07 bo 00 act 00 dr 00 r-L L!l fY► N 00 D6 Ln et � N LPl m -qf Ln N Ln � Cn TH "G at N QS ry G fC d1 E CL C [SS L9 Y G Q,} P C L i q 0 0 LD fEt CU tto Z >���� cs° f°LL' E C cu c di S C LLu � :3 ■- LL Ln w LL C 0 C 0 ca z w CD E C L9 dl u1 �p "0 0 W C @ Ln W L � Q +, 2 oC a a 0 w a� L6 tia u C M 0 G C W a) u 0 Q d7 Lr, N U co L ¢ � 'V LU LIL y ry N Eiy 11 LU (u m E La D- U D� iu U 0 Ln L fL L71 Lv CTl �--I L!) 0 00 CT r- C7 0 0 0 C7 00 e-i C7 OD N N U3 i- c!` Ln L n 0 0 - O O C7 rN-9 V-1 CD 0 Ln 0 C? 00 act 00 dr 00 r-L L!l fY► N 00 D6 Ln et � N LPl m -qf Ln N Ln � Cn TH at N QS ry fC E W cc Lf) C ) Lp Q H -i irn N W c3 � N Ln rn Na, 00 ' m 6 nL Ln 0 d m t H oc + n .a 00 ❑ 'Ln m N w a �• Dc O rH * Ln . i , I co 0 LA co M rL �i d d a n e-1 m coo N Ln n ac N N C3 © s-, LO ko cz til co LD m Ln CO n 0 N LD 4 M cY r 1 LD 00 C7 Cn rJ Ln fY! 0 4 M co m Q N r-1 Cif LD I� LJ I C) � � c�L t4 m cm 1`• R N Ln N n M Lei C [SS L9 Y G Q,} P C L i q 0 0 LD fEt CU tto Z >���� cs° f°LL' E C cu c di S C LLu � :3 ■- LL Ln w LL C 0 C 0 ca z w CD E C L9 dl u1 �p "0 0 W C @ Ln W L � Q +, 2 oC a a 0 w a� L6 tia u C M 0 G C W a) u 0 Q d7 Lr, N U co L ¢ � 'V LU LIL y ry N Eiy 11 LU (u m E La D- U D� iu U 0 Ln L fL DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC h) Agency Budget L Is your agency currently receiving and/or requesting other (non -Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) No If yes, please list below: Include ail programs that have funding requests/awards/totals from Carrboro, Chapel Herr, and Qran-ge Coun€ governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY17 -18 Award FYI 8-19 Request Source Ex: Affordable Rental Rehabilitation 0 $20,000 Carrboro - Affordable Housing Ex: Agency Administration $15,000 $15,000 Carrboro — Other — Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate 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 o Private Donations * Program Generated Revenue o Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) Arurmrrr lnfnrmation 112.,419ti1R R-.E'id-nn AAA P n 1-1 r -�, I I o f '9 ri DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Govemment (CDBGIHOME/etc.) • Private Foundation Grants o Other Revenue ,Expenditures o Compensation o Rent & Utilities o Supplies & Equipment o Travel & Training o Other Expenses iii. Does your agency budget show a Surplus or Deficit? deficit Is there a significant charge? Yes /No yes Please provide a brief explanation for Surplus or Deficit, and significant changes. Financial contributions are down agency -wide. Some of our foundations have changed their focus from human services to areas such as the environment and social justice; only half of the anticipated FEMAIEFSP allocation was received in November 2017, the remainder is pending; the Triangle United Way allocation was cut by 75% in July 2017. Perhaps due to the numerous natural disasters happening in other parts of the country, donors are choosing to make their charitable donations to these disasters instead of keeping their finances local. iv. What is your agency's fiscal year? January 1, 2018 through December 31, 2 018 (Example: July 1, 2016 through June 30, 2017) Am-nrsr rnfnrrnatinn 719:1419t)lp PAA P p ri p 11A n f 9 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name. Meals on Wheels Program Primary Contact and Title: Kay Stagnerj Manager of Client Services Telephone Number. 919 -732- 6194 ex. 12 E -Mail. ocimsrm@embargmail.com 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 X 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 Housln Affordable Healthcare - Education Family Resources JobslJobs Training — Food X X X Transportation Other- Please specify c) Provide a bulleted list of other agencies, if any, with which your agency coordinateslcollaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated /collaborative efforts. 0 Orange County Department of Social Services: Meals on Wheels receives referrals about passible recipients from Adult Services social workers. • Orange County Department on Aging: Meals on Wheels receives referrals about possible recipients_ Likewise, the Meals on Wheels Coordinator makes referrals to the Department on Aging when recipients seem to be in need of other services or there are health or safety concerns. ® Various home health agencies: social workers, nurses and aides make referrals for their clients. • Area congregations: Members of area congregations volunteer for Meals on Wheels as well as refer people who may need home - delivered meals. Orange County Employees, PHE, Sports Endeavors, Bourough Business Builders: Employees give up a lunch hour to deliver Meals on Wheels. PpnrRAn.1 ►A►nRnnAT►nnl if9- w9nls n -�e -nn AAA :) ,; DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC Meals on Wheels Association of America: CCIM's Meals on Wheels program is a member of the national organization which provides information, training, and networking opportunities. "Mayors for Meals" is an event sponsored through MOWAA. This annual event involves mayors from local communities in the delivery of meals on the third Wednesday of March. Through this event, local governments become more aware of Meals on Wheels and the needs of the elderly in our community. Hillsborough's mayor, Tom Stevens, has participated in this event for many years- Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority /goal? The Meals on Wheels program provides a nourishing, home delivered lunch, five days a week to homebound residents of northern Change County. This program addresses Orange County's Goal 1: i=nsure a community network of basic human services and infrastructure that maintains, protects, and promotes the well -being of all county residents. The Meals on Wheels program ensures the people it serves are receiving a nutritious meal, five days a week. The volunteers are able to make a quick assessment of each recipient's physical and cognitive condition; if there appears to be a change in condition, it is reported to the program coordinator who follows through with the recipient's emergency contact or Orange County agencies as appropriate. This network maintains consistent contact with the most fragile members of this community, as well as promoting well - being, by providing at least one nutritious meal a day, five days a week. e) Describe the community need or problem to be addressed in rotation to the Ch del Hrll Human Services Needs Assessment, Crane County B ©CC Goals and Priorities, Town of Camel bill Council Goals, Carrboro Boars" Priorities, or other community priorities (i.e. Council /Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Kumar? Services Needs Assessment) to support the need for this program. According to Change County's Master Aging Plan, the number of adults age 65+ is estimated to increase by 31% between 2012 -2017. By 2030, this population will more than double from its size in 2012, reaching an estimated 31,063 people and making up 17.6% of all Orange County individuals. Orange Congregations In Mission's Meals on Wheels program desires to make sure the most fragile members of the northern Grange County communities receive a home - delivered lunch and accompanying visit by the delivery volunteer.. Extra effort is being made to serve people in the very northern part of Grange County, which is currently out of reasonable driving range for volunteers. By partnering with Orange County and utilizing the Cedar Grove Community Center as a drop -off location for meals, the driving distance and time will be greatly reduced for volunteers. FRnr.' AA.4 iAiFnPAAATil7Ai 119.119018 R- .5d-nn Anir ti DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC fj Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The people who qualify for OCIM's Meals on Wheels program are home alone during the day, unable to prepare a nutritious meal for themselves due to either physical or cognitive disability, and are no longer driving. The individuals this program serves are normally unable to participate in the programs available at the Central Orange Senior Center. Many of the Meals on !Wheels recipients are very low income, though the program is open to any person who meets the qualifications. Ideally, if a person has sufficient financial resources, other options are available. A more vague qualification has been whether the person being referred lives within, or near, an existing Meals on Wheels route. When the Meals on Wheels Coordinator receives a referral, she calls either the person needing the service or an identified family member. Basic questions are asked, including where in Orange County they live. If it appears the person meets the qualifications, the coordinator goes to the home to get clear directions and to discuss the financial sliding scale. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) The Meals on Wheels Program Coordinator has been running OCIM's Meals on Wheels program for 11 years. As a former secretary and office manager to a prosecuting attorney, she is able to manage a very detailed and very confidential program_ When the Meals on Wheels Coordinator is unavailable, the Manager of Client Services- program supervisor fills in. Volunteer drivers have had references checked and Confidentiality Statement signed prior to volunteering. They are given an orientation and then assigned to a route. Route books are very self - explanatory, if the volunteer is uncomfortable, they are encouraged to ride along with an experienced driver the first time_ h) Describe the specific period over which the activities will be carried out and include an implementation timeline. Meals are delivered Monday through Friday, between 10:30 and 12:00, During winter storms, when the Orange County Schools are closed due to road conditions, the Meals on Wheels program does not deliver. Prior to anticipated storms, an additional meal of non-perishable items is sent with the understanding that no meal will be delivered if roads are dangerous. 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) The Meals on Wheels program serves the most fragile of northern Orange County's residents. Receiving a nutritious lunch is one part of allowing seniors to "age in place. " By providing a daily "well- being" check, significant changes in physical condition and cognitive behaviors can be recognized and the Coordinator is able to alert absent family members to potential problems. There have been several Ppnr,PAA/I /AfFn PUATinm 1f ?.ifgn7R R-.s,&nn AAA P n ri p 17 o f 9R DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC occasions when a recipient has fallen. Without someone checking can them, a minor situation can easily escalate to an emergency. In the case of an emergency, ,Emergency Services is called. The need for expansion to the more northern parts of the county is an issue this Meals on Wheels program has been wrestling with for several years. All routes are driven by volunteers, many of whom drive during their lunch break from work. The time it would take and the price of gasoline have been prohibitive in reaching people in the Cedar Grove and Little River townships. By using the Cedar Grove Community Center as a secondary food distribution site, it is hoped residents from those communities would be more likely to volunteer to drive. Having enough volunteers would make it viable to add recipients who may have previously lived too far away to serve. Caring for the elderly and infirmed is a vital component of a healthy community. �) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. If the current Meals on Wheels program did not receive funding from {Orange County, the program would be unable to continue as it currently exists_ Without the Orange County funds, so few meals could be purchased that the program would have to either offer no sliding payment scale and only be available to people who could afford the full cost or only be available to a very few people. If there is no funding for personnel support, there would be no expansion of routes to the Cedar Grove and Little River areas_ A new position for a Meals on Wheels Assistant would be imperative; the part-time Meals on Wheels Coordinator would not be able to transport, supervise, and be available to drive a route if a volunteer does not show up, while also being available to do the same thing for the existing six routes. k) What percentage of your target population is low- moderate income? 99% 1) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc. ?) No formal surveys have been made, but the Meals on Wheels Coordinator is in frequent contact with recipients. Anecdotally, the vast majority of people are very pleased with the food and the volunteers who deliver the meals. We have tried to issue a survey to the recipients in the past but had very few responses returned. m) Include any other pertinent information. A part -time employee to help with getting meals to the more rural parts of Orange County has not been hired yet, funding to hire came in October. The search for the right person for this position will begin during Change County's 2017 -18 third quarter. PpnrPAM mivnPA114 Tinny 119 ?19n -i R 17- AP -.cin Pnrr P A r(P 12 n r 7�; DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC Additional Program Information nj 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 Actual Estimated Projected 2017 1 2018 2099 Gender Male Female Total Ethnicity African American American Indian or Alaska Native Asian Caucasian Native Hawaiian or other Pacific Islander Other. • specify Total Of the above, how marry Hispanic/Latino Of the above, how many nun- Hispanic/Latino Age Geographic Location Total 0 -5 years 6 -18 years 19 -50 years 51 + years 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) 24 24 24 69 79 79 93 103 103 33 68 68 103 103 0 103 103 60 65 65 103 103 6 52 60 60 93 103 903 Total 1 931 1031 103 PRnr,PAA/1 iNFr"' pwTinAi 119'419nlR R _Fd -nf) AM F" P. rr r� n f � -; 0 0 103 103 0 103 103 Total 1 931 1031 103 PRnr,PAA/1 iNFr"' pwTinAi 119'419nlR R _Fd -nf) AM F" P. rr r� n f � -; 4 4 4 89 99 99 93 103 103 Total 1 931 1031 103 PRnr,PAA/1 iNFr"' pwTinAi 119'419nlR R _Fd -nf) AM F" P. rr r� n f � -; 36 37 37 5 6 6 52 60 60 Total 1 931 1031 103 PRnr,PAA/1 iNFr"' pwTinAi 119'419nlR R _Fd -nf) AM F" P. rr r� n f � -; DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC 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 9 Program Activity, which should be SMART (�_Specific, pleasurable, Achievable, _Relevant, and Time- bound. Click on SMART Goals to learn more. a 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.) 0 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.) S 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: Meals on Wheels 1. Program Activity Name Deliver meals to elderly /disabled residents. -- Program Goal Deliver 49 meals per day (93 people for the year), Monday- Friday. Performance Measures Will track the number of meals delivered each day. Previous Year Program Results 93 people received meals in 2017, daily average of Current Year Estimated Results 103 people will receive meals in 2018, daily average of. Next Year Projected Results 103 people will receive meals in 2019, daily average of 2. Program Activity Name Increase meal delivery to the Cedar Grove and Little River townships. Program Goal Deliver meals to an additional six people, distributed from the Cedar Grove Community Center. Performance Measures Will track the number of meals delivered each day. Previous Year Program Results This is a new initiative. �- This is a new initiative. Six people in the Cedar Grove and Little River townships will receive Meals on !ili►'heels delivery- Current Year Estimated Results Next Year Projected Results 3. Program Activity Name Program Goal - Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results _ Ppnr,'RAM 1A1FnPAAATInAl 11?w9 l9R R•_9;d•M AAA P a rl in 9a o f 29; DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC m ri a N LU u a! �O i CL 00 ur `� N a ru c E ui h C3 N s.. aJ aJ u a ca s as 0 + m ro � CL u � Q bn m 0 L Vi 2 a- C ,,n C N C Q i-3 ro ,} aJ C O LU C a1 D w z R3 LLJ rn LLJ 0 Ln it 0 © Lfl C7 r C7 (D Ln (] :t r-1 Q1 0 n C) C) C7 e-L CD C7 c--4 C7 m 'j C7 f V ® XD co "I r Ln t:) C? N CD w Ln Ln "t "D cQ cf c_7 ' o r 00 a m m C7 Lr) a) 0 w Lf i 00 Lry rri 4, M o n G% & o n7 0 c5 0; m -4 Ln m m -i m r 00 m a7 C? C) Ln CD r' C] 0 Ln n d rl 00 ri. C7 C] C] C7 C� r! C7 C� rI Ca m n! C> LO 00 o4 -4 LJI 0 C? N C? 00 Lip Ln d' LD cD cr C? C] r 00 0 m Ln C] Ln Ln © 00 Lr rr' 00 LJ7 m d re CT r a7 & C7 N 6 C] C m rL Ln m m r-+ m r 00 m m m ct m V 00 r Lra r-i Ict C7 o Ln LO n r• Lf) -1 iD CJi r-- LD er cn Ln -4 co " 't m m .-L C� m ct .1 r -+ yr to rI;t LO C7 d- -1 r.1 eq p Ln M M--I S O r l r- 1.6 -- lz:� flci er rri cw` rt i r i r- r# r: N 14 m m W1 00 r rV Lrl Ln CD m et m Ln rrs c cu L bii > } qJ L1J aJ aJ ,L 4l 7 > Y C � Q a ai Ln z C] !JJ nf M C d C m Ln Li- } VY w V cR � C ` - a aJ F C} C) ru i 41 as +� -0 C Lu ai � J= C) Ln a c w L LL- r ca m w CU u p aD O, aJ C 0 W tn U 0 C Ln C1 E ti C+} C -0 O � C co 4. o aJ aJ _� 7 C " z Q1 _ a--� •0 rII L C a! �'-� aJ Qi t 7 - uj E aJ >M cJ 0 b p ro s- � trJ -c c r 0 a cj i1. , LL p i CL 0 � Q i` ® 0 � � � U Ln 4= i� DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC p) Program Budget 1. Submit your program budget. You may complete the provided template (separate x1s 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 • Garrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hit/ Other (DOS 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 (CDBGAHONIE/etc.) Private Foundation Grants • Other Revenue Expenditures o Compensation o Rent & Utilities o Supplies & Equipment o Travel & Training o Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. 3. Miscellaneous/Other Income includes interest, recycling revenue, dividend and investment 4. This program budget represents what percent of the agency budget? .57 %® 5. COST PER INDIVIDUAL This Cost per Individual must reflect the total program budget divided by the total number of program individuals in this application. Ppnr.PAM [AlFnRMA TinAi 719119nl R 9-9d1 •dR PM P z14 ri 1-1 "3 ;, o i Actual 2016 -17 Estimated 2017 -18 Projected 2418 -19 Total Cost of Program 507,794 499,881 499,881 Total # of Individuals J 9,841 -- - 9,841 9,841 Cost Per Individual 52.87 50.80 50.80 Ppnr.PAM [AlFnRMA TinAi 719119nl R 9-9d1 •dR PM P z14 ri 1-1 "3 ;, o i DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC ATTACHMENT B SCOPE OF WORK Orange County Department of Social Services Federal Tax Id. or SSN 58- 1563438 Contract # NA A. CONTRACTOR INFORMATION 1. Contractor Agency Name: Orange Congregations in Mission 2. If different from Contract Administrator Information in General Contract: Address Telephone Number: _ Fax Number: Email: 3. Name of Program (s): TmeMency Assistance 4. Status: ( ) Public (X) Private, Not for Profit ( ) Private, For Profit 5. Contractor's Financial Reporting Year July 1, 2018 through June 30, 2019 B. Explanation of Services to be provided and to whom: Through the Emergency Assistance Program, the Contractor will assist eligible individuals with rent and related costs as well as Town of Hillsborough water bills and related costs, The County will reimburse the Contractor up to $3 000 /month unless prior approval by County, for a total of $36,000 for the contract period for rent/related costs and/or Town of Hillsborough bills /related costs. To be eligible clients must: be residents of Orange County, have income at or below 200% of the Federal Poverty Level, and have a household cUeriencing a financial crisis. Pa merits are limited to 200 within a 12 -month period. The Couft will also reimburse the Contractor for staff costs (including saIaLy, FICA and fringe) for administering the Emergency Assistance Program up to $15,000 for the contract period The Contractor will program paperwork provided by County at time and dates designated by County. C. Funding reimbursement limits by category: Rent/related costs and Town of Hillsborough bills/related costs $36,000 ($3,000 per month) Staff costs: salary FICA, fringe X15,000 D. Number of units to be provided: NA E. Details of Billing process and Time Frames: The County will reimburse the Contractor for services described in this contract up to the budgetary limits of the contract allotment. The Counly will reimburse the Contractor for actual ex enditures for approved services provided. For reimbursement the Contractor must submit copies of bills, checks, receipts and/or other proof of ex enditures by the fifth of the month for the preceding month's expenditures to the designated County Administrator. The Contractor must submit a pMment records for staff cost reimbursement. The County will reimburse the Contractor monthly upon receipt of a complete and correctly filed report. F. Area to be served/Delivery site(s): Orange County Contract -Scope of Work (06/04) Page lof 2 DocuSign Envelope ID: EBOFBDBE -FD15- 4428 - 8998- 19A867F94OCC DocuSigned. by, N w6w DocuSigned by: SLw6v, �. rV't.dA AJ DAE1E198A83B455... Nancy Coston, Social Services Director BE &2EM675A483... (Signature of Contractor) 9/10/2018 9/7/2018 (Date Submitted) (Date Submitted) Contract -Scope of Work (06/04) page 2of 2 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC EXMI1T "C" Scope of Services — FY 2018 -19 Outside Agency Performance .Agreement Agency Name: Orange Congregations in Mission, Inc. Program Name: Samaritan Relief Ministry Funding Award: $37,500 Outline how the aeenev will spend Orange County's funding award. Expense Description Amount Personnel:program manager salM 8,000 Rent and utility assistance 10,000 Food 19,500 Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2019. • Provide a week's worth of groceries to referred households a maximum of seven times in twelve months. • Provide emergency financial assistance for rent and utilities. 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 Number of meals /grocery services provided to qualifying households 9,184 Number of qualifying households receiving emergency financial assistance for rent and utilities 175 D"uSigned by: %Y6n. S rmd alnD Certified by: I 6E62EC9D&75A483 . (Provider's Signature) e: Executive Director Date: 9/7/2018 Orange County Outside Agency Performance Agreement Revised 612018 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC EXHIBIT "C» Scope of Services — FY 2018 -19 Outside Agency Performance Agreement Agency Name: Orange Congregations in Mission, Inc. Program Name: Meals on Wheels Funding Award: $40,215 Outline how the agency will spend Orange County's funding award. Expense Description Amount Meals on Wheels meal purchases $20,107.50 Personnel- salary and mileage to su pport programming at Orange County Cedar Grove Center $20,107.50 Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2019. • Delivery meals to elderly /disabled residents five days/week (Monday- Friday) • Increase meal delivery to Cedar Grove and Little River Townships 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 Number of meals delivered 10,237 Number of new direct interviews conducted and/or individuals enrolled in program from Cedar Grove or Little River Townships 20 DocuSigned by: . s bw s. r�J Certified by: 6E62EC6D &75A483... (Provider's Signature) 0: Executive Director Date: 9/7/2018 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC EXHIBIT "C" Scope of Services — FY 2015 -19 Outside Agency Performance Agreement Agency Name: Orange Congregations in Mission, Inc. Program Name: Direct Food Delivery Funding Award: $7,267 Outline how the agency will spend Orange County's funding award. Expense Description Amount Meals and supplemental items $7,267 Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by .Tune 30, 2019. Provide food delivery to an increased number of qualifying Orange County citizens. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Or. ante County, on (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 Number of additional meals delivered 2,100 Number of additional people in meal program 7 DacuSign(ed�by: • S[o, S• rmaaja Executive Director Certified �' BE &2EM675A483... (Provider's Signature) Date: 9/7/2018 3 DocuSign Envelope ID: EBOFBDBE -FD15- 4428- 899B- 19A867F94OCC OP ID: LP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY) 05/0212018 THIS CERTIFICATE I5 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 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 INSR 4A'AE ' Jeff Rubish NAME: High & Rubish Insurance Agency ORANGE COUNTY PHONE 919 -�� -1144 FAX N.1; 919. 913 -1154 P.O. Box 3040 6415 Farrington Rd. Ste 141 Ph I �Y EXP c 4 Ext - E-MAIL natalie@highandrubish.com Chapel Hill, NC 27517 Jeffrey A. Rubish A PRODUCER r E D ,OCIM --1 ECP0349072 INSURERS AFFORDING COVERAGE NAIC 9 INSURED Orange Congregations In $ 2,000,00 $ 2,00{x,00 $ 10,00 INSURER A: Cincinnati Insurance Company 10677 Missions, Inc. $ 2,000,00 INSURER B ; Hartford Underwriters Ins. 30104 300 Millstone Drive $ 4,000,00 GENT AGGREGATE LIMITAPPLIES PER X POLICY PRO LOC PRODUCTS - COMP/OP AGG Hillsborough, NC 27278 INSURER C: - A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS X HIRED AUTOS X NON -OWNED AUTOS - -- EBA0349072 I 14N512415 INSURER D: COMBINED SINGLE LIMIT (Ea accident) $ 2,000,00 $ $ $ $ BODILY INJURY (Per person) INSURER E : PROPERTY DAMAGE (PER ACCIDENT) INSURER F: r•_nv�an[_F -c Cr-RTIFICATF NIIMRER! 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 TYPE OF INSURANCE X ORANGE COUNTY POLICY NUMBER INM1RbY E Y� Ph I �Y EXP LIMITS AUTHORIZED REPRESENTATIVE + `r A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS-MADE a OCCUR ECP0349072 1011512075 I4i1�Si21 }7$ EACH OCCURRENCE $ 2,000,00 $ 2,00{x,00 $ 10,00 DAMAGE MFRI!�� PREMISES (Ea xwrrence MED EXP (Any one person) PERSONAL B ADV INJURY $ 2,000,00 GENERAL AGGREGATE $ 4,000,00 GENT AGGREGATE LIMITAPPLIES PER X POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 4,000,00 $ A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS X HIRED AUTOS X NON -OWNED AUTOS EBA0349072 I 14N512415 1011512018 COMBINED SINGLE LIMIT (Ea accident) $ 2,000,00 $ $ $ $ BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (PER ACCIDENT) $ UMBRELLA LIAR EXCESS LIAR OCCUR CLAIMS -MADE. EACH OCCURRENCE $ AGGREGATE. $ DEDUCTIBLE RETENTION $ $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEWEXECUTIVE YIN OFFICERIMEMBER EXCLUDED? �I (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 22WECBV6360 08/18/2017 08/1812018 X 4VC STATU- TH- E L. EACH ACCIDENT $ 100,00 E.L. DISEASE -EA EMPLOYEE $ 100,00 El- DISEASE LIMIT 504 00 $ r A Sexual Misconduct 'ECP0349072 05/0212018 10/15/2018 Occurence 1,000,00 Aggregate 1,000,00 DESCRIPTION OF OPERATIONS LOCATIONS! VEHICLES Attach ACORD 101, Addltionai Remarks Schedule, if more space Is required) Additional Insured Status Applies to Holder r- coTrrlr -ATr_ ury nGO CANCELLATION ORANG -1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ORANGE COUNTY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. P O Box 8181 302 W. Tryon St.. Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE + `r (P 1988 -2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD