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2017-665-E Finance - ARC of the Triangle outside agency agreement
DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2017, ("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 The Arc of the Triangle, a not-for-profit corporation, located at 1709 Legion Road, Suite 100, Chapel Hill,NC 27514("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need,as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth,the County and The Arc of the Triangle agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2017 to June 30, 2018. 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 B, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of 6450 b. All funds appropriated shall be used for purposes described in 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, 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 1612.5. 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. (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Revised 712017 Page I of 7 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 -June 30. Reports are due on January 12,April 13, and July 13 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. (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7117 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker's Compensation. For protection from claims under workers'or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury,including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance,including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents,consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A-Statutory State NC&Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $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. (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7117 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD 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 $ 13.75 per hour. To the extent possible, Orange County recommends that The Arc of the Triangle 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: (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7117 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD County: Finance&Administrative Services Provider: The Arc of the Triangle Orange County 1709 Legion Road, Suite 100 Post Office Box 8181 Chapel Hill,NC 27514 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. 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. 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.orangecountync.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 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF,the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For ai UocuSigneedd by, 'r 12/21/2017 3703EC�A�A98489... Date (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7117 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD For 6 DocuSigned by: —aunty Government 1/12/2018 O�i379946755E477 Bonnie Hammersley, County Manager Date (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7117 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FY 2017-2015 Outside Agency Funding Application HUMAN SERVICES ORANGE COUNTY • TOWN OF CARRBORO • TOWN OF CHAPEL HILL Orange County (OC) Town of Carrboro (CA) Town of Chapel Hill (CH) 200 S. Cameron Street 301 W. Main Street 405 Martin Luther King, Jr. Blvd. Hillsborough, NC 27278 Carrboro, NC 27510 Chapel Hill, NC 27514 CA ti o DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION INFORMATION Each year, Orange County Government, the Town of Carrboro and the Town of Chapel Hill invite ,program funding requests from non-profit providers that support the delivery of vital community services. The application process is very competitive and not all applicants will be awarded funding. Recommendations for funding may be for an award amount less than that requested by the applicant. Agencies that are currently receiving funds from Orange County, the Town of Carrboro, or the Town of Chapel Hill local governments, and are also applying for new funds, must be in compliance with all terms of their current agreement(s) and must not have any outstanding audit findings, monitoring findings or concerns as determined by the municipality. Recipients are required to submit written progress reports on their SMART Measures that include: goals, description of activities/challenges, revisions of timelines/budgets, and other relevant information Funded projects will be monitored for progress and performance, financial and administrative management, and compliance with the terms of Performance/Development Agreement(s). Monitoring may involve site and/or office visit(s). Once applications are received, they are reviewed by staff for completeness and eligibility. The applications are presented to a specific application review group, depending on the funding source. The review group will make a recommendation, based on available funding and the priorities identified by the participating jurisdiction. The recommendation is presented to the appropriate Board/Council for consideration and approval. The Board/Council approves/adopts the final allocations. TIMELINE November 15 Funding Application Posted on Websites November 29 Funding Application Workshop Held October 18-January 23 Agency Prepares Application January 10 Q&A Session Held January 31 Application Submissions are Due March _ May Application Review & Agency Presentations June Agency Funding Approval by Board/Council July Contracts Executed & Programs Begin DO NOT SUBMIT THIS PAGE 1/26/2017 5:52:39 PM P a g e 2 of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION SUBMITTAL INFORMATION Welcome to the Outside Agency Common Funding application for local/general funds, which will be distributed through this competitive application process. All entities or organizations requesting funds must complete and submit this application prior to the deadline to be considered for FY 2017-2018 funding. The Application Submittal Deadline is: Tuesday, January 31, 2017 5:00 PM In the event of inclement weather, check the website for each Town/County you are applying to, for further instructions. Please note that late, handwritten, or incomplete applications will not be accepted. (Applications not signed by the Chair or President of the Board of Directors, are considered incomplete.) An application orientation workshop will tentatively be held on Tuesday, November 29, 2016 at 9 AM to Noon to review the application and submittal requirements. SUBMITTAL REQUIREMENTS FOR EACH MUNICIPALITY Human Services— Town Of Carrboro Applications are accepted once a year and reviewed by the Town's Human Services Advisory Commission, which makes a recommendation for funding to the Board of Aldermen for final approval. For more information about the Town of Carrboro Human Services program, see here. Questions and submittals should be directed to: Annette Stone, 301 W. Main Street Carrboro, NC 27510 919-918-7319 astone townofcarrboro.or Submission: We strongly encourage applications to be single-spaced, with 12-point axial font and normal margins. Application: One (1) original plus Two (2) paper copies of the application must be hand delivered or mailed to Annette Stone, 301 West Main Street, Carrboro, NC 27510; AND One Application and Attachments files must be submitted by email. Any .pdf files must be accompanied by the original file format of .doc, .xis, etc. DO NOT SUBMIT THIS PAGE 1/26/2017 5:52:39 PM Page 3 of 2 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Human Services — Town Of Chapel Hill In 1982, the Town established local funding to support local nonprofit organizations that carry out human service work throughout the community. Applications are accepted once a year and reviewed by the Town's Human Services Advisory Board, which makes a recommendation for funding to the Town Council for final approval. For more information about the Town of Chapel Hill Human Services program, see here. Questions and submittals should be directed to: Jackie Thompson 405 Martin Luther King Jr. Blvd. Chapel Hill, NC 27514 919-969-5081 ithom son townofcha elhill.or Submission: y We strongly encourage applications to be single-spaced, with 12-point arial font and normal margins. Application: Two (2) paper copies of the application with ORIGINAL signatures must be hand delivered or mailed to Jackie Thompson, 405 Martin Luther King, Jr. Blvd., Chapel Hill, NC 27514; AND Attachments: The application submittal must be accompanied by a flash drive with the application and all attachment files in electronic format. Any .pdf files must be accompanied by the original file format of .doc, .xIs, etc. Human Services— Orange Coun For more information about the Orange County Human Services program, see here. Questions and submittals should be directed to: Allen Coleman PO Box 8181 Hillsborough, NC 27278 (919) 245-2151 acoleman(cD,orangecountync.gov Submission: ➢ Email application and ALL Attachments prior to the deadline. Any .pdf files must be accompanied by the original file format of .doc, .xIs, etc. Please request a delivery receipt of email with application and attachments. DO NOT SUBMIT THIS PAGE 1/26/2017 5:52:39 PM Page 4 of 2 6 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency The Arc of the Triangle FOR OFFICE USE ONLY Received By Program(s) Social, Volunteer, Individual Services Date/Time Section Subsection 1. Cover Page a. x Applicant Contact Information b. x Funding Requests C. ❑ Signed Application Cover Page d. ❑Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. x Agency's Years in operation b. x Agency's Purpose/Mission c. x Agency's Types of Services Provided d. x Agency's Experience with Programs e. x Other Pertinent Agency Information f. x Schedule of Positions g. x Living Wage h. x Agency Budget 3. Program Information a. x Human Services Needs Priority b. x Type of Program A separate Section 3 is c. x Agency Collaboration required for each program. d. x Summary of Program e. x Description of Identified Need f. x Description of Population to be Served g. x Program Staffing, Capacity, & Expertise h. x Program Implementation Timeline L x Value of Investment j. x Impact of Reduced/No Allocation k. x Other Pertinent Information I. x Target Population/Beneficiary Chart M. x Work Statement n. x Program Budget, Detail, & Cost per Individual 4. Attachments a. ❑ Audit: Organizations receiving $300,000 or more in Federal financial assistance, and/or organizations with more than $500,000 of receipts and expenditures in a fiscal year, must secure an audit. b. x IRS Federal Form 990 c. x NC Solicitation License d. x IRS Federal Tax-Exemption Letter e. x Certificate of Insurance f. x List of Board of Directors g. x Solid Waste Program Fee(SWPF)Verification Application Submittal Checklist 1/26/2017 5:52:39 PM P a g e 5 of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: The Arc of the Triangle, Inc. Applicant Organization's Physical Address: 1709 Legion Road Suite 100 CH NC 27517 Applicant Organization's Mailing Address: same Applicant Organization's Web Address: www.arctriangle.org Executive Director: Jennifer Pfaltzgraff Telephone Number: 919 942 5119 xt 117 E-Mail: ipfaltzgraffsa�__arctriangle.org Tax ID Number: 56-1214133 b) Funding Request List all FY17-18 Human Services (HS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro FHi�l el Orange Total - HS HS Count -HS Ex. Youth Afterschool Program $10,000 00 $5:000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects Social and Volunteer Programs, Individual Services, $7,500.00 $12,000.00 $7500.00 $27,000.00 Petals with a Purpose, Health and Wellness Cooking Class, HOOPs Basketball, Spin Class, Friday Fun Day, HOPE Gardens, Summer Work and Wellness Program. Funding used to cover supplies, materials, brochures, publicity, salary. Totals $7500.00 $12,000.00 $7500.00 $27,000.00 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: t E4 c ]ve Director Date Signature: LLB/ Board Chair rson Date AGENCY INFORMAT N 1/26/2017 5:52;39 PM Page 6 of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT 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? ❑ M c) Current beneficiaries of the program for which funds are being requested? ❑ E 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: X/'� l 1—+— x c iv irector Date Signature: Board ChrN on Date AGENCY INFORMAT 1/26/20 17 5:52:39 PM Page i of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 2. AGENCY INFORMATION (Be Very Brief and Concise) Please provide the following information about your agency (2 pages OR LESS): a) Years in Operation, Date of Incorporation (Month/Year): 38 years, December 1979 b) Agency's Purpose/Mission (no more than a few sentences): The Arc of the Triangle ("The Arc") works with and for people who have or are at risk for having intellectual and/or developmental disabilities (i/DD). We strive to provide quality support to the individual, their family and the community in which they live. Additionally, The Arc seeks to promote the full participation of the people we serve in all areas of life in our community accomplishing this through advocacy, education and community collaboration. c) Types of Services the Agency Provides (bullet format): 1. Individual Services provides a Support Professional to work with your child or loved one to teach independence and provide support in the home and the community. Support Professionals are trained and paid staff hired and employed through The Arc that work one-on- one with our individuals in the following areas of their lives: • in Home Skill Building provides techniques that help teach individuals to acquire and maintain skills to increase independence. It can be provided in the home or in the community, working on goals such as increasing community living skills, daily living skills and social skills. • Personal Care provides support with bathing, feeding, dressing, and maintaining personal hygiene. • Respite provides the family or loved one with a break in care. This service can be provided in the home or in the community. 2. Supported Employment provides employment assistance to individuals sixteen years old and older. This can include pre-training to prepare a person for meaningful work and assisting the individual to start a micro-enterprise. Support Professionals can assist the individual with initial job training, coaching and maintaining skills learned on the job. 3. Summer Work and Wellness Program (SWWP) SWWP is a full-time summer program that focuses on building job skills as well as fun and social opportunities for those with I/DD ages fifteen through twenty-one years old. The program is geared to help individuals transition out of school and into paid employment. 4. Community Health Wellness and Volunteer Social Programs Because The Arc's goal is for everyone to lead purposeful and healthy lives that make a difference, our social programs encourage our individuals to get involved and give back. These social programs are led by volunteers who teach healthy lifestyles while encouraging giving back to the community: • Nutrition and Cooking Class allows adults to use hands-on experience to further their knowledge of nutrition as well as their skills in the kitchen. Each week a different "head- chef' picks out a recipe to prepare in the class with everyone cooking together. Giving back to the community means once a month thirty-six desserts are prepared and donated to local Meals on Wheels families. • Petals with a Purpose is an effort to connect flowers to people in the community all the while making a difference on the environment. Using items destined for the landfill such as soup cans, glass, and water bottles, individuals with and without disabilities gather together each week to create beautiful flower vases. Fresh flowers are donated by Whole Foods every week. The flower vases are then delivered to people in hospice care, senior citizens, food pantries and events in the community, most recently Chapel Hill's Appreciation Luncheon and Strowd Rose's fifteen-year celebration at Estes Park and Community Center. We proudly think of this program as "A-R-C" - Acts of Random Compassion that spreads ripples of goodwill into the community. Agency Information 1/26/2017 5:52:39 PM P a g e 8 of 2 6 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • HOOPs Basketball, Spin Class weekly basketball and cardio spin classes led by volunteers who encourage everyone to shoot some hoops, practice drills, and spin on stationary bicycles while listening to upbeat music, all the white having fun, incorporating healthy lifestyle choices and making friends in the process. • HOPE Gardens (Homeless Outreach Poverty Eradication) a community garden founded by UNC-CH School of Poverty and Justice Students that offers garden beds to local non-profits and economically stressed people. Arc rents two garden beds where we grow food for our cooking class and flowers for our Petals with a Purpose program. Participants learn firsthand where our food comes from allowing them to make better and healthy food choices and gaining the ability to use fresh food while cooking at home. • Friday Fun Day a social program that emphasizes individuals have fun while learning about a topic of their choice, or visiting/touring a place that they might otherwise not ordinarily visit. 5. Community Connections Partner Program CCPP - is a special friendship created when a volunteer is connected with an individual with I/DD. Together they form a community partnership spending a few hours each month exploring activities they both enjoy, for example going to the movies, eating out, playing sports, taking a hike. d) Agency's History with Providing These Services: The Arc of the Triangle originally formed thirty-eight years ago to serve individuals with Intellectual and Developmental Disabilities (I/DD) living in Orange County, North Carolina. Where no other similar agencies existed, The Arc identified the need to provide people with healthy and purposeful life choices. Through the success of these programs The Arc expanded to include Supported Employment and Social and Volunteer Opportunities. What began then as a small organization in 1979, The Arc of Orange County, recently merged with Durham and Wake County, forming The Arc of the Triangle. The goal is to provide Durham and Wake County residents with the same high quality and high level of service that Orange County residents have become accustomed to over the years. Other programs and agencies that were similar to The Arc have gone out of business due to decreased funding or due to a lack of quality and comprehensive services. 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?) Effective November 2016, Robin Baker is no longer the Executive Director of The Arc. A search committee has been formed and started the process of interviewing and hiring a new Executive Director. Jennifer Pfaltzgraff, a current Arc employee and past Executive Director of The Arc of Wake County, is serving as Interim Executive Director. 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: 20 # of FTE - Paid Part-Time Positions: 57.5 # of Volunteers: 40 # of FTE -Volunteers:4.24 Agency Information 1/26/2017 5:52:39 PM P age 9 of 2 6 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION g) Living Wage Cues this agency pay permanent employees a minimum living wage? (Yes/No) NO If yes, is this agency an Orange County Living Wage Certified Employer? NO If no, please explain. We pay well above the state mandated minimum wage but we do not yet meet Orange County's living wage standard. Our reimbursement rate from Medicaid for some of our services such as personal care and respite care are not reimbursed at a rate high enough to pay a living wage at this point. Where other agencies have discontinued, or were forced to discontinue these lower reimbursable services, The Arc feels morally and professionally responsible to continue to provide services even though the reimbursement rate does not allow us to increase staff wages. Agency Information 1/2612017 5:52:39 PM Page 10 of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION h) Agency Budget i. Is your agency currently receiving and/or requesting other(non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (Yes/No) NO If yes, please list below: Include all programs that have funding requestslawardsltotals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FYI 6-17 FYI 7-18 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro -Affordable Housing Rehabilitation Ex: Agency Administration $15,000 $10,000 Carrboro— Other Ex. Total $15,000 $35,000 Carrboro Total Funding *Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template). Agency Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues • Private Donations • Program Generated Revenue • Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) Agency Information 1/26/2017 5:52:39 PM Page 'I 'I of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT 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 (CDBGIHOMEIetc.) • 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? No. Is there a significant change? Yes/No Yes. Please provide a brief explanation for Surplus or Deficit, and significant changes. After the merger of three local Arc chapters (Orange, Wake and Durham) in .duly 2014, The Arc of the Triangle's leadership did not budget for the changes in the way our agency would work across the Triangle as a much larger entity providing more services and resources to a myriad of individuals and families. We chose to spend reserves to make sure that everyone was served and received the services and programs they needed. But realizing this was not the way to continue doing business for the long term, The Arc of the Triangle's Finance Committee of the Board of Directors has worked extensively with the Executive Director and senior staff to re-allocate resources (staff positions/job duties, use of office space and equipment), increase revenues, and cut costs with everyday expenses and salaries. iv. What is your agency's fiscal year? July 12016 through June 30 2017 (Example: July 1, 2016 through June 30, 2097) Agency Information 1/26/2017 5:52:39 PM Pa g e 12 of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: The Arc of the Triangle Social Volunteer and Individual Services Program Primary Contact and Title: Susan Chandler Telephone Number: 919 942 5119 E-Mail schandlerp_arctriangle.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 X Family Resources X Jobs/Jobs Training X Food X Transportation Other: Please specify c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. • The North Carolina Division of Vocational Rehabilitation (VR) - persons recommended to The Arc from VR find gainful work with Arc Supported Employment Specialists. • Cardinal Innovations Health Care Solutions- families and individuals are recommended to The Arc to receive Home and Community Support, Respite Care, Supported Employment, Social and Volunteer opportunities. • Meals on Wheels (MOW)— Arc participants volunteer weekly delivering and preparing meals for Chapel Hill and Carrboro Meals on Wheels recipients. Once a month the Arc's cooking class bakes and donates thirty-six desserts to local MOW recipients. • Whole Foods — donates buckets and buckets of beautiful fresh flowers every Wednesday for the Petals with a Purpose program. • Extraordinary Ventures (EV) -- Arc participants are hired and employed at EV for a variety of jobs including Office Solutions, EV Laundry, EV Candle making, EV Pet sitting, as well as partnering in Friday Night Live a weekly evening at EV for PROGRAM INFORMATION 1/26/2017 5:52:39 PM P a g e 1 3 o f 2 6 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION friendship and fun for teens and adults with or without intellectual/developmental disabilities. • EZ Rider and Public Transportation - Arc participants use the free public bus system to access the community for their employment, education and social activities. • The Seymour Center - Arc participants volunteer weekly at the Seymour Center assisting and creating friendships with senior citizens, The Arc's Petals with a Purpose program also supplies monthly lunch bouquets honoring senior birthdays that month. • RSVP (Retired Seniors Volunteer Program) - senior citizen's volunteer with The Arc's social programs such as Petals with a Purpose and Spin class. • UNC Wellness Center Meadowmont - Arc Spin, Weight and HOOPS basketball meet weekly at the health club at no charge to The Arc. • The Chapel Hill Carrboro Chamber of Commerce - each fall the Chamber sponsors one Arc employee to participate in the Chapel Hill Carrboro Chamber's Leadership Series. • The Hillsborough Chamber of Commerce - Arc staff speaks biannually to educate and encourage Hillsborough residents to utilize Arc services and programs. • Sororities and Fraternities at UNC APO ZTA Phi Beta Chi and PKP Arc's volunteer programs are comprised of a large percentage of sorority and fraternity students. Students organize major fundraisers for the benefit of The Arc (Tar Heel 10 Miler, ZTA Race for the Cure.) • The Knights of Columbus - raise awareness and funding for The Arc's programs through the LAMB's Tootsie Roll event each year. • The Cardinal Track Club and others - The Arc is chosen as one of the local non-profits to benefit from the awareness and the money raised from these three annual races: Annual "Turkey Gallop and Gorge," "Four on the Fourth," and Tour de Carrboro in October. • The Meadowmont Homeowners Association annual yard sale donating all proceeds to The Arc, welcoming to Arc individuals residing in Meadowmont townhomes built and designated for persons with intellectual and developmental disabilities (9 individuals total.) • PNC Bank,_Chapel Hill - each Wednesday the Petals with a Purpose program gathers in a PNC conference room at no charge to The Arc. • Hargraves Community Center- on Tuesdays Hargraves hosts The Arc's health and wellness cooking class allowing us to use the center at no charge. • Mardi Gras Bowling -- on periodic Fridays, Arc individuals enjoy bowling alongside people with and without disabilities. • Amante Pizza - on periodic Fridays, Arc individuals enjoy lunching at Amante's alongside people with and without disabilities. • The Root Cellar- encourages their staff to volunteer at The Arc. Each week the Petals with a Purpose program donates flower bouquets with Arc's information on each vase. The vases are displayed on their tables so patrons of the restaurant can learn about The Arc, take home and enjoy a free flower vase compliments of The Arc's "Acts of Random Compassion" Petals with a Purpose Program. People seeing these vases have contacted us to become volunteers with the Petals program. Just today we received a call from a film making student that wants to do a documentary on the Petals Program after witnessing the delivery of vases to the Root Cellar and the joy that it brought to many. • HOPE Gardens (Homeless Outreach Poverty Eradication program) - UNC School of Justice students converted an unused fourteen-acre piece of land into community gardens and offered local non-profits small garden beds to rent to grow vegetables, herbs, fruits, and flowers of their choosing. For the past six years, The Arc has rented two of these garden beds, growing food for cooking class and planting PROGRAM INFORMATION 1/26/2017 5:52:09 PM Page F 0F :' DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION flowers to use in the Petals with a Purpose program. Surplus of the food we grow goes home with our individuals, or is donated to the local food pantry at St. Joseph's Church Food Pantry and to the Senior Center. The cooking class goes to the garden so individuals can learn firsthand how to grow organic food, make healthier food choices, and be in a peaceful setting enjoying the outdoors. • UNC School of Journalism and Public Relations — students intern thirty hours each semester creating videos, website, blogs, and marketing materials for The Arc. They also participate in The Arc's Spin, HOOPS basketball and cooking classes. • St. Joseph's Church in Carrboro - each week the Petals with a Purpose program donates two dozen flower vases for the St. Joseph's food pantry, so that recipients combine gifts of beauty to nourish their souls along with food to nourish their bodies. Several years ago, one of the food pantry patrons took home a Petals with a Purpose flower vase with Arc's information on it, contacted us and is now working as an Arc Direct Care Staff. The Petals program led this person to find employment at The Arc and to be in a position of giving back to the community. L• Summer Work and Wellness Program: apel Hill Job Placements: Cafe Carolina The Egg & I Brixx Pizza Chapel Hill. Public Library Seawell Elementary School East Chapel Hill High School Smith Middle School Market Street Coffee Weaver St. Market The Franklin Hotel & Carolina Meadows Green Beagle Lodge Weaver St. Southern Village[Tobacco Road Ace Town & County Hardware Great Clips (Meadowmont) Great Clips (Chapel Hill North/MLK) Elements Orange County Animal Shelter Rashkis Elementary Voices Together Durham Job Placements: Freddy's Habitat Restore Marshalls 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? People with intellectual and developmental disabilities (IIDD) often lead lives that have limited opportunities for social inclusion and participation. Restricted and sedentary lifestyles significantly reduce the quality of life. Funding for these PROGRAM INFORMATION 1126/2017 5:52:39 PM Page 15 of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION programs will go directly to coordinate and monitor activities that enable people with IIDD to become engaged with the community through the use of community volunteers, spaces and resources. This is consistent with the Chapel Hill, Carrboro and Orange County town goals of Creating a Place for Everyone and Nurturing Our Community. Social programs are important for people with development disabilities because there are fewer opportunities once individuals age out of the school system. Furthermore, people with IIDD have statistically higher rates of unemployment as well as limited choices in continuing education such as college or higher level degrees. The Arc finds it unacceptable for someone with IIDD to stay home with little more to do than watch TV. Individuals with IIDD can and should be contributing members of the community in all aspects of their lives. Our social programs meet those needs for our individuals. The Arc's social programs, supported employment and individual services have many components that are educational, social, and community driven in nature demonstrating that healthy lives are happy lives and happy lives are purposeful lives. Our social programs (cooking class, HOOPs basketball, Spin class and Petals with a Purpose) are completely led by volunteers allowing the programs to be cost effective. Not having to pay for an instructor or teacher to lead our programs considerably cuts down on the cost of the programs, not to mention showcasing and using the talented, creative and enthusiastic local neighborhood volunteers who contribute to making our community a better place for everyone. Because learning shouldn't stop after leaving the classroom, social programs like Friday Fun Day emphasize having fun while learning about a topic or a place they might not ordinarily visit. These activities may enrich the lives of our people in ways both expected and unexpected. For example, a recent Friday Fun Day tour of the local radio station WCHL, resulted in an intern position being offered to one of our Arc participants, and a tour of the NC Botanical Gardens (NCBG) resulted in the offer of free NCBG memberships for our individuals, families and staff. An important byproduct of our individuals enjoying and being seen in the community as capable and contributing members of society is that the community's perception of a person with IIDD is elevated and changed for the better. This results in forming positive impressions and mutually beneficial relationships with the community, so that when there is a job opening or a volunteer opportunity the community will not think twice to employ, hire, or extend these opportunities to someone with a disability: a win-win on all levels. This is an example of the governing principal of "Building a better community with res ect." The weekly cooking class teaches culinary skills in a hands-on and encouraging kitchen setting, and demonstrates that working together as a team is the best way to get the job done. "Team work makes the dream work." In an effort to teach the joys of civic duty by giving back to the community, once a month the class bakes and donates thirty-six desserts to the local Meals on Wheels program. The recipes made in class are easily duplicated to be made at home allowing our individuals to lead healthier lives with better and proper nutrition. HOPE Community Gardens is a valuable and free food resource for individuals with IIDD. Arc participants and Arc volunteers maintain the gardens and can bring home fresh organic food without having to pay or travel to grocery stores. Much of the food grown also finds its way to the local food pantries and to the senior center, so PROGRAM INFORMATION 1/26/2017 5:52:39 PM P a, c e "'a 0 f 1. DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION others in need in our community can enjoy eating nutritious and locally grown food. The Petals with a Purpose program connects flowers to people. Each week a group of individuals, both with and without disabilities, gather together in the community to create flower vases as "Acts of Random Compassion" (A — R C) that have a rippling effect of good will in the community. They recycle and repurpose items destined for the landfill including soup cans, or water, juice and wine bottles that are transformed by their creative talents into vases of flowers. Our local Whole Foods donates beautiful fresh flowers every week. The flower vases are then delivered into the community to places like St. Joseph's food pantry and the Seymour Senior Center, and to local events like the Special Olympics, Stroud Rose's Anniversary Celebration, and the Town of Chapel Hill's Annual Appreciation Luncheon (where Mayor Pam Hemminger publically acknowledged our program.) Recipients of the flower arrangements receive free gifts of beauty, learn about The Arc, and will continue to enjoy reusing the Petals with Purpose vase at home; importantly all this with a focus to keep our landfills less filled! When individuals with UDD are contributing to the community in a positive way, then we are further along in reaching our goals of Creating a Place for Everyone and Nurturing our Communities. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. The Arc programs meet multiple needs that are top priorities for the Chapel Hill and Carrboro Human Services Advisory Boards, Orange County and the Towns of Chapel Hill and Carrboro. We provide Educational and Family Resources for our clients through the cooking and exercise classes described above. We teach civic engagement, Nurturing Our Community, by working together to create flower arrangements or food creations that are then donated to other local nonprofit or governmental agencies. The HOPE Community gardens offer a local place for our individuals to grow healthy food that they can take home, stretching their income by not having to pay for the food or the travel to other grocery stores. People with IIDD live on very limited budgets and organic, fresh food is often expensive and less accessible. Much of the food grown is also shared and donated to food pantries, Seymour Senior Center and Meals on Wheels, thereby providing more food to more people, anad helping to nurture and feed our community in any small but meaningful way that we can. Through our classes and our Friday Fun Days, we provide happy, supported opportunities for vital socializing with both I/DD peers and the overall local community. Our Supported Employment program and Summer Work and Wellness program complement these activities by teaching job skills. We put a lot of effort into helping IIDD people become comfortable with using our local public transportation such as the free town bus systems and the UNC EZ Rider to get to and from programs. All these pieces come together to help Creating a Place for Everyone. PROGRAM INFORMATION 1/26/2017 5:52:39 PM Page 'i of 26; DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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 Arc provides supports and services to more than three hundred adults and children with IIDD. People identified with IIDD are individuals that have autism, Cerebral palsy, Down syndrome, epilepsy and individuals that are classified as PDDNOS (Pervasive Development Delay Not Otherwise Specified). Referrals for our services are made through Medicaid, Dept. of Health and Human Services, LME's, (Local Management Entities such as Cardinal Innovations, Alliance) schools, educational facilities and word of mouth. The Arc is among an already small network of agencies providing support and services to individuals in the community that is rapidly decreasing because of budget cuts, in spite of an ever higher and ever increasing number of people needing our assistance. 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 Assistant Director of Social and Volunteer Programs is a Certified Volunteer Administrator (CVANC), credentialed in the state of North Carolina, having completed a one year course in volunteer management. The Assistant Director is also a certified C&I (Communications and Interaction Strategies) training instructor. C&I training focuses on healthy interactions with persons with IIDD. These trainings are given to all Arc paid staff and Are volunteers in addition to the on-on-one training they currently receive. Arc staff that oversee participant caseloads are certified Qualified Professionals. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. All social programs and individual service are currently implemented and are offered ongoing throughout the year. 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) A growing body of research has found that the presence of social capital through creation of social networks and communities has a protective quality on health. Social capital affects health risk behavior in the sense that individuals who are embedded in a network or community rich in support, social trust, information, and norms, have resources that help achieve health goals. For example, a person who is sick with cancer may receive information, money, or moral support he or she needs to endure treatment and recover. Social capital also encourages social trust and membership. These factors can discourage individuals from engaging in risky health behaviors such as smoking and binge drinking. Experts call this social capital; I call it my personal life experience. Attached is an article I wrote for the local news that reflects on raising my son who has autism. When he was diagnosed twenty-five years ago I was given this advice that I still find pertinent today "Use every experience as a learning experience, keep your son engaged in the community with typically developing children and most importantly PROGRAM INFORMATION 1/26/2017 5:52:39 PM to c; e i o DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION to never give up." I use my son as a barometer for The Arc programs we offer. The social programs need to meet the high standard of quality I expect not just for my child but for every childlindividual in the community. Studies of social capital indicate that a typical individual has one hundred and fifty healthy relationships in their life; a person with I/DD has twenty five. The Arc's educational, social and employment programs and the highly trained, highly skilled volunteers and staff who lead these efforts provide a unique source of valuable social capital and social networking for people with IIDD to use in navigating through life's challenges and opportunities. These individuals count towards increasing the number of healthy relationships in a person's life. The goal of The Arc is for our social classes and programs to help significantly increase the amount of these social capital relationships. Our social programs are led by volunteers allowing The Arc to offer these classes while not having to pay for people to run them. The volunteers are enthusiastic have an interest in the classes and have the desire to make a positive difference in the life of a person with 1/DD. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. It has been shown that people live longer and have happier lives when they have friendships, good nutrition and exercise, purpose in their life, and social capital. When people lead isolated and lonely lives their health suffers and they are prone to more emergency room visits and costly medical care. The Arc believes in using our programs to proactively help people with IIDD lead happy, productive lives, so in the long run an ounce of prevention is worth more (and costs much less) than a pound of cure. If the requested funding amount is reduced or not awarded, we will not be able to serve as many people with these programs. k) Include any other pertinent information. The Arc continues to face the economic reality of providing more services to more people while having less funding available. Medicaid reimbursement for one service known as Developmental Therapy (DT) was completely eliminated. This meant a decrease of$190,000 to cover serving people that we continue to support. Our Local Management Entity (LME) has also moved 40% of the people we support to a payment category called "non-habilitative" services that are reimbursed at a lower rate. We continue to serve these people in the same manner, but with less reimbursement. In 2015 the LME also changed the reimbursement rate for two of the other services that we provide. The result is a $3,000 per month reduction in funding. The United Way was a notable source of Arc funding, however their mission no longer addresses the needs of people with IIDD, so that funding source is gone. To fill in these gaps, we are taking a two-pronged approach: we are actively evaluating our processes and resources for delivering our programs to find ways to accomplish our goals more efficiently, and we are also working hard to diversity our funding sources, such as through this grant application. PROGRAM INFORMATION 1/26/2017 5:52:39 PM Page 19 of t DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION In addition, by The Arc's use of volunteers to lead all our social programs, we have effectively cut out the significant cost of paying people to teach these social classes. The Arc has continued to provide these vital programs to people that need them the most by utilizing the talent in our local community, and simultaneously creating meaningful relationships and saving money. PROGRAM INFORMATION 1/26/2617 5:52:39 PM P a g e 20 o f 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information 1) 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 2015-16 2016-17 2017-18 Gender Male 259 298 342 Female 125 144 166 Total 384 442 1 508 Ethnicity African-American 65 75 86 American Indian or Alaska Native 7 8 9 Asian 13 15 17 Caucasian 197 227 261 Native Hawaiian or other Pacific Islander Included in "other'category below Other: specify 102 117 135 Total 384 442 508 Of the above, how many Hispanic/Latino 12 14 16 Of the above, how many non-Hispanic/Latino 372 428 492 Total 384 442 508 Age 0-5 years 5 6 7 6-18 years 83 96 110 19-50 years 254 293 337 51+years 42 47 54 Total 384 442 508 Geographic Location Alamance County 1 1 1 Chatham County 10 12 14 Durham County 13 15 17 Wake County 168 193 222 Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non-Public Housing) 125 144 166 Town of Carrboro 13 15 17 Town of Hillsborough 16 18 21 City of Mebane (Orange County) 10 12 13 Orange County (Outside Municipalities) 28 32 37 Total 384 442 508 PROGRAM INFORMATION 1/2612017 5:52:39 PM P a g e 2 1 of 2 6 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement m) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 900 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 The Arc of the Triangle: Social, Volunteer and Individual Services 1. Program Activity Name Engagement in Inclusive and Civic-Minded Community Activities: Petals with a Purpose and HOPE Community Gardens Program Goal Using a combination of paid Direct Support Professionals and Volunteers, thirty-two people with IlDD will increase engagement in non-segregated environments where individuals participate in civic minded and community activities such as the Petals with a Purpose program and volunteering at the HOPE gardens that give back to the community at large. Performance Measures Person-centered plans, daily service notes and annual surveys provide data to verify this information. Previous Year Program Results Out of one hundred-ninety two people served, half (ninety-six) increased their participation in community activities that included but were not limited to: educational opportunities, volunteer and paid work, advocacy activities, community minded activities, religious activities and social functions. Thirty people have participated in activities such as Petals with a Purpose and HOPE Gardens that give back to the community at large Current Year Estimated Results Out of two-hundred twenty one people served, half (one-hundred ten) people will increase their participation in community activities that include but are not limited to: educational opportunities, volunteer and paid work, advocacy activities, religious activities and social functions. Thirty-two people participate in activities such as Petals with a Purpose and HOPE Gardens that give back to the community at large. Next Year Projected Results Out of two-hundred fifty four people served, half (one-hundred twenty seven) will increase their participation in community activities that include but are not limited to: educational opportunities, volunteer and paid work, advocacy activities, reli ious activities and social functions. Thirty six people will PROGRAM INFORMATION 1/25/2017 5:52:39 PM Page 22 of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION participate in activities such as Petals with a Purpose and HOPE Gardens that give back to the community at large. 2. Program Activity Name Relationship Building and Social Capital: Community Connections Partner Program Program Goal Twenty persons served will increase the number of relationships and people in their circle of support by having a Community Connection Partner. Performance Measures Person-centered plans, daily service notes and annual surveys provide data to verify this information. Previous Year Program Results Twenty participants increased the number of relationships and people in their circle of support by having a Community Connections Partner. Current Year Estimated Results Twenty participants have increased the number of relationships and people in their circle of support by having a Community Connections Partner. Next Year Projected Results Twenty-three participants will increase the number of relationships and people in their circle of support by having a Community Connections Partner. 3. Program Activity Name Healthier Lifestyles: Exercise, Social and Nutrition Classes Program Goal Using a combination of paid Direct Support Professionals and Volunteers, sixty people served will learn about and participate in leading healthy lifestyles. This includes participation in Cooking Classes, Friday Fun Day, HOOPS basketball and Spin Class. Performance Measures Person-centered plans, daily service notes and annual surveys provide data to verify this information. Previous Year Program Results Fifty people increased their health by participating in Cooking Classes, Friday Fun Day, HOOPs basketball and Spin class. Current Year Estimated Results Sixty people increased their health by participating in Cooking Classes, Friday Fun Day, HOOPs basketball and Spin Class, Next Year Projected Results Seventy people will increase their health by participating in cooking and nutrition classes, Friday Fun Day, and exercise classes. PROGRAM INFORMATION 1/2612017 5:52:39 PM P a a e 2 o f 2 6 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION n) Program Budget 1. Submit your program budget. You may complete the provided template (separate As file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues o Private Donations a Program Generated Revenue a Local Government Grants • Carrboro Human Services • Carrboro Other • Chapel Hill Human Services • Chapel Hill Other (DO NOT include CDBG funding here) • Orange County Human Services • Orange County Other (DO NOT Include HOME funding here) o Other Government Grants • Triangle United Way • State Government • Federal Government (CDBG/HOME/etc.) • Private Foundation Grants o Other Revenue • Expenditures • Compensation • Rent & Utilities • Supplies & Equipment • Travel & Training • Other Expenses 2. Program Budget Detail — Provide description of "other" budget items, not defined. 3. This program budget represents what percent of the agency budget? 1.5% 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. Actual 2015-16 Estimated 2016-17 Projected 2017-18 Total Cost of Program $52,500.00 $51,500.00 $51,500.00 Total # of Individuals 96 106 127 Cost Per Individual $5.49 $4.68 $3.90 PROGRAM INFORMATION 1/26/2017 5:52:39 PM P a g e 24 of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 4, ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY 2015, for calendar year agencies, and FY 2015-16, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit/report should not complete the form. b) IRS Federal Form 990 A copy of the agency's 2014 Form 990 is required. The specific form depends upon the agency's financial activity. Review the IRS' table guide, for more details. For Form 990-N (e- postcard) filers, include a copy of the postcard, with the agency's application materials. c) NC Solicitation License A copy of the agency's current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State's licensing website and its Frequently Asked Questions Guide PDF , about exemptions, if exempt per N.C.G.S. § 131 F-3, include a copy of the exemption letter with the agency's application materials. d) IRS Federal Tax-Exemption Letter A copy of the agency's IRS tax-exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS' Customer Account Services. e) Certificate of LiabilitV Insurance A copy of the agency's current certificate, from the agency's insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker's Compensation compliance, include a statement explaining why, with the agency's application materials. *Note. If Approved for Funding Approved agencies must provide an updated insurance certificate. The update should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July I — June 30), Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. DO NOT SUBMIT THIS PAGE 1/26/2017 5:52:39 PM P a g e 25 of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORo TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Limits for Coverage Compensation' A - Statutory State Limits for Coverage A - Limits for Coverage A - NC, for each Statutory State NC, for Statutory State NC, for employee each employee each employee Limits for Coverage Limits for Coverage B - Limits for Coverage B - B - Employers Employers Liability of: Employers Liability of: Liability of: $100,000 Each Occurrence $500,000 each $1 million Each $100,000 BID for each accident, $500,000 Occurrence employee BID for each employee $1,000,000 BID2 $500,000 BID limit $500,000 for BID limit limit Commercial $100,000 Property General Damage Liability $1 million Each Liability $1,000,000 Bodily $1 million Each Occurrence Occurrence Injury and Property $2 million Aggregate $2 million Aggregate Damage Limit Automobile Not Applicable $1 million Each Occurrence $500,000 Each Liability Occurrence Professional $1 million Each Liability Not Applicable Not Applicable Occurrence $2 million Aggregate 1. Visit the NC Industrial Commission's website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen's compensation insurance. 2. Bodily Injury by Disease (BID) 3. Please visit Orange County's contracts webpage for more information about the County's risk assessment procedures. f) List of Board of Directors Provide the following information about each board of director's member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. g) Solid Waste_Program Fee (SWPF) Verification This fee finances Orange County's recycling and waste reduction program. Submit either a.) proof of payment of the agency's FY 2016-17 Solid Waste Program Fee, OR b.) a statement on agency letter head indicating exemption and specify the person(s), business, etc. that is responsible for paying this fee. DO NOT SUBMIT THIS PAGE 1/26/2017 5:52:39 PM Page 26 of 26 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVID APPLICATION . t Life lessens from 'my sweet, beautiful son' 81(SUSAH PAUL 'Stop crying,honey"said the In some ways the news on Feb. head UCIA-neuropsychologist. 11,1993,came `But my son was going to be as a relief.' president," I said through my For three tears, years I had "Well stop crying, because if fretted,wor- Dan Quayle isvice president,then �a y ried and was the sky is the limit for your son." puzzled, why Right then and there I learned my sweet, to laugh. beautiful son So I went from the"Mommy was not wav- & Me" group in my neighbor- Paul ing"bye-bye,,' hood to the "Autism Support,r not feeding Group for Parents,". s' himwX not doingwhatall the other children his age did with ease. SEE LESSONS, 'PAGE A7 CONTRIBUTED PHOTO Alex Paul puts his arm around a new friend in kindergarten. f LESSONS to look for a place to live." I have been through tough tithes, FROM PAGE Al Right then and there I learned but I don't have a tough life," support.'(We called ourselves the I learned bravery,in the face of "MOHAWKS" . Mothers and his everyday challenge, I went from hearing toddlers in Others Having Autistic Kids.) For the morns and dads,grand- MY son's playgroup point to their In kindergarten, through an- parents,friends and siblings,let the mother's belly with continents like other set of tears, I asked his share this with you:Never give up "there's a baby growing in my teacher,'Do.you think he will learn hope, surround yourselves with "D mommy's uterus"to the story of to read?" o you think he will those that support you, get in- the another traveling.across the ever have friends?" volved,give back and never,ever country with her child with autism "Yes,without a doubt to both" give up. and two typical children, When she said. . her son refused to reboard the His teacher retrieved a photo Susan Paul,the mother of an 18- plane in Memphis, tying up the• that I.still have to this day with my year-old son with autism,works passengers and crew,she turned to son's arms around-his classmates. 'with The Arc of Orange County her children and said,"'OK,then, And there I learned to trust, as the family intake coordinator we are staying and living now in When I asked my son if he had and director of a new volunteer Memphis.Come'on kids,we need a tough life,he answered,"Mom, program. DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: The Arc of the Triangle Actual 2015- Estimated 2016- Projected 2017- Percent AGENCY REVENUE 16 17 18 Change Private Donations $ 18,282 $ 35,000 $ 36,000 3% Agency Generated Revenue(fees) $ 2,960,831 $ 3,015,000 $ 3,020,000 0% Local Government Grants: Human Services-Town of Carrboro $ 3,615 $ 5,000 $ 7,500 50% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ 5,000 $ - $ 12,000 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 5,000 $ 6,000 $ 7,500 25% Other-Orange County $ - $ - $ 0 Other-Town of Hillsborough $ - $ - $ _ 0 Other Government Grants Triangle United Way $ 3,315.00 $ 4,500.001 $ 4,500.00 1 $ - State Government $ 155,000.00 $ 155,000.00 1 $ 155,000.00 $ - Federal Government(CDBGIHOMEIetc.) $ 55,000.00 $ 65,000.00 1 $ 60,000.00 $ 0.08 Private Foundation Grants $ 33,344.00 $ 41,000.001 $ 41,000,00 1 $ - Other Revenue $ 59,695 $ 85,000 $ 85,000 $ - Total Agency Revenue $ 3,299,082 $ 3,411,500 $ 3,428,500 0% AGENCY EXPENSES Compensation $ 2,606,889 $ 2,500,000 $ 2,510 000 0% Rent&Utilities $ 88,041 $ 88,100 $ 88,100 0% Supplies&Equipment $ 21,562 $ 17,000 $ 18,000 6% Travel&Training $ 6,007 $ 6,000 $ 8,000 33% Other Expenses: $ 813,825 $ 800,400 $ 804,400 0% Total Agency Expenses $ 3,536,324 $ 3,411,500 $ 3,428,500 0% SURPLUS/(DEFICIT) FOR PERIOD: $ (237,242) $ - $ - 0 FY 2015-16 Comparative Agency Budget Revised 9129/2014 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: The Arc of the Triangle Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ 811 $ 1,500 $ 2,500 67% Program Generated Revenue $ 4,385 $ 4,500 $ 4,500 0% Local Government Grants: Human Services-Town of Carrboro $ 3,615 $ 5,000 $ 7,500 50% Other-Town of Carrboro $ - $ _ 0 Human Services-Town of Chapel Hill $ 5,000 $ - $ 12,500 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ - $ - $ - 0 Other-Orange County $ 6,250 $ 6,000 $ 7,500 25% Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ _ $ _ $ _ 0 State Government $ 36 000.00 $ - 0 Federal Government(CDBG/HOMEletc.) $ - $ _ $ _ 0 Private Foundation Grants $ 26,414.00 $ 35,500.00 $ 16,000.00 $ 0.55 Other Revenue $ _ $ _ $ - 0 Total Program Revenue $ 81,475 $ 52,500 $ 50,600 -40 PROGRAM EXPENSES Compensation $ 48,133 $ 48,133 $ 48,133 0% Rent&Utilities $ 1,652 $ 1,652 $ 1,652 0% Supplies& Equipment $ 2,403 $ 1,500 $ 1,500 0% Travel&Training $ 350 $ 200 $ 200 0% Other Expenses: $ _ $ _ $ - 0 Total Program Expenses $ 52,538 $ 51,485 Is 51,485 0% SURPLUS/(DEFICIT) FOR PERIOD: $ 28,937 $ 1,015 $ (985)1 197% DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD EXHIBIT `B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: The Arc of the Triangle Program Name: Social,Volunteer and Individual Services Funding Award: $6,450.00 Outline how the agency will spend Orange County's funding award. Expense Description Amount Program Supplies for Cooking Class,Petals with a Purpose Program,HOPE Gardens $3,500.00 Rent,Utilities $1,475.00 Salary $1,475.00 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Cooking class members learn to make healthy food choices, cook nutritious meals, use recipes from class at home, and engage with each other socially. Once a month as a community service the class bakes dessert for the local Meals on Wheels program. • Petals with a Purpose class members give back to the community by repurposing items destined for the landfill like soup cans and glass bottles transforming them into flower vases. Each week at least 40 vases filled with fresh flowers are donated into the community to places like the Seymour Senior Center,hospice, St. Joseph's food pantry. • Community Connections Partner Program matches up an adult with someone who has a disability. Together they enjoy activities like community outings and form a friendship along the way. • HOPE Community Gardens allows our individuals first hand to see how food grows, creates access to organic food and encourages everyone to use the food from the gardens for healthy meals at home. 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 Cooking Class has 20 individuals in class with I/DD,4 volunteers and 20 Direct Care Staff. 100% continue in class Petals with a Purpose program has 24 individuals in class with I/DD,4 volunteers and 20 Direct 100% Care Staff continue in class HOPE Community Gardens has 4 individuals with I/DD and 4 Direct Care staff 100% continue in l�Docu5ignnedd by: class + q Certified by: �`s�osECaa3_.._... �.�.1;: �� — 0�i ce` Date: 2' (Provider's Signature) a r l DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD ATTACHMENT "A" Orange County Certifications—FY 2017-18 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. DOCU Signed by: YVAA�} rr nff Certified by: 133703ECDADA18491 Title: Executive Director Date: 12 21 2017 (Provider's Signature) (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7117 DocuSign Envelope ID:7B55B196-3912-4C1A-ADB4-A753058DFEFD ARCOF-4 OP ID: KB ,a►cosz° CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 164. � 1 06121/2017 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 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 Kendra A Biddle,CPCU,CIC Marsh&McLennan Agency-CLT P HONE Fax 440 South Church St.,Ste 500 A/c No, arc,No):336-841-5319 Charlotte,NC 28202 ADDRESS:kbiddle @senndunn.com M.Bryan Beasley,CIC INSURER(S)AFFORDING COVERAGE NAIC A INSURER A:Key Risk Insurance Company INSURED The Arc of the Triangle,Inc. INSURER B:Selective Insurance Co of Amer 12572 1709 Legion Road,Suite 100 Chapel Hill, INC 27517 INSURER C: INSURER D: INSURER E: INSURER F: 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 TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR IN POLICY NUMBER MM/DD/YYYY MMIDDIYYYY B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 TO RENTED CLAIMS-MADE Al OCCUR 52258874 07/01/2017 07/01/2018 PREMISES Ea occurrence $ 1,000,00 MED EXP(Any one person) $ 20,000 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,00 POLICY 1-1 PRO- JECT F—] LOC PRODUCTS-COMP/OP AGG $ 3,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident B ANY AUTO 52258874 07101/2017 07/0112018 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,00 B EXCESS LIAB CLAIMS-MADE S2258874 07/01/2017 07/01/2018 AGGREGATE $ 1,000,00 DED I X I RETENTION$ 0 $ WORKERS COMPENSATION X IR AND EMPLOYERS'LIABILITY STATUTE PER E ER A ANY PROPRIETOR/PARTNER/EXECUTIVE YIN KEY0137206 07/04/2017 07/04/2018 E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBER EXCLUDED? ❑N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,00 B Professional S2258874 07/0112017 07/01/2018 Incident 1,000,00 Liability Aggregate 3,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION ORANGI8 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County Government ACCORDANCE WITH THE POLICY PROVISIONS. Finance&Administrative Sery 200 S Cameron Street AUTHORIZED REPRESENTATIVE PO Box 8181 ` 1� a Hillsborough, NC 27278 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD