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2017-713-E Finance - Tides outside agency agreement
DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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 Tides Center, a not-for-profit corporation, located at 1014 Torney Avenue Presidio Building#1014, San Francisco,NC 94129 ("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 Tides Center 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 750 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 187.5. 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. (Tides Center) Orange County Outside Agency Performance Agreement Revised 712017 Page I of 7 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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. (Tides Center) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7117 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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. (Tides Center) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7117 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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 Tides Center 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: (Tides Center) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7117 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 County: Finance&Administrative Services Provider: Tides Center Orange County 1014 Torney Avenue Presidio Post Office Box 8181 Building#1014 Hillsborough,NC 27278 San Francisco,NC 94129 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 QocuSigned,bbyy,, Provider 12/7/2017 _11B85F4809ED5B424 , Date (Tides Center) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7117 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 For,E6E0637994B755E477... 00cu Signed by, 'ountyGovernment 6lnJlnAl. N*ML1r5bj 12/11/2017 Bonnie Hammersley, County Manager Date (Tides Center) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7117 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FY 2017-2018 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 ,Y.L, �o �o ;,Are + L •.: �T$CAR��� DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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 1/31/2017 3:01:12 PM Page 2 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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(a)_townofcarrboro.org Submission: We strongly encourage applications to be single-spaced, with 12-point arial 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 1/31/2017 3:01:12 PM P a g e 3 o f 1 8 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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 jthompson(a�townofchapelhilLorg Submission: ➢ 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 County 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(a_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 1/31/2017 3:01:12 PM Page 4 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency Tides Center Received By Program(s) Youth Forward Date/Time / Section Subsection 1. Cover Page a. ® Applicant Contact Information b. ® Funding Requests c. ® Signed Application Cover Page d. ®Signed Disclosure of Conflicts of Interest and Clause 2. Agency Information a. ® Agency's Years in operation b. ® Agency's Purpose/Mission c. ® Agency's Types of Services Provided d. ® Agency's Experience with Programs e. ® Other Pertinent Agency Information f. ® Schedule of Positions g. ® Living Wage h. ® Agency Budget 3. Program Information a. ® Human Services Needs Priority b. ® Type of Program A separate Section 3 is c. ® Agency Collaboration required for each program. d. ® Summary of Program e. ® Description of Identified Need f. ® Description of Population to be Served g. ® Program Staffing, Capacity, & Expertise h. ❑ Program Implementation Timeline L ® Value of Investment j. ® Impact of Reduced/No Allocation k. ® Other Pertinent Information I. ® Target Population/Beneficiary Chart m. ® Work Statement n. ® 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. ® IRS Federal Form 990 c. ® NC Solicitation License d. ® IRS Federal Tax-Exemption Letter e. ® Certificate of Insurance f. ® List of Board of Directors g. ® Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 1/31/2017 3:01:12 PM Page 5 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Tides Center Applicant Organization's Physical Address: 1012 Torney Ave., San Francisco, CA 94129-1755 Applicant Organization's Mailing Address: PO Box 29907, San Francisco, CA 94129-0907 Applicant Organization's Web Address: www.tides.org Executive Director: Tabitha Blackwell (Protect Executive Director for Youth Forward) Telephone Number: (919) 960-1673 E-Mail: tblackwell(a-)_chcyouth.org Tax ID Number: 94-3213100 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 Chapel Orange Total - HS Hill -HS County-HS Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects ConnectMe! App 5,000 10,000 5,000 20,000 Funds for developer and staff salary to finalize and launch an app to assist youth and parents find services Totals c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: 01 / 30 /2017 xecutive Director Date Signature: 0,1V4 01 / 30 /2017 Board Chairperson Date AGENCY INFORMATION 1/30/2017 8:39:52 PM Page 6 of 17 Doc ID:2eb6ac1433140dd445c9fc9978251c59361ba75e DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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? ❑ ® c) Current beneficiaries of the program for which funds are being requested? ❑ ® d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner.-;, To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: 01 / 30 /2017 Executive Director Date Signature: �`fr-r 01 / 30 /2017 Board Chairperson Date AGENCY INFORMATION 1/30/2017 8:39:52 PM Page 7 of 17 Doc ID:2eb6ac1433140dd445c9fc9978251c59361ba75e DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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): Tides became Youth Forward's fiscal agent on January 2014 b) Agency's Purpose/Mission (no more than a few sentences): Tides accelerates the pace of social change, working with innovative partners to solve society's toughest problems. Youth Forward, a project of Tides Center, is dedicated to advance a seamless array of services aligned to the needs of all youth in Chapel Hill/Carrboro by working with nonprofits, schools, local governments and others. c) Types of Services the Agency Provides (bullet format): Youth Forward provides three key activities: • Connecting: Creating tools (website and app) to increase awareness of nonprofits serving youth. • Capacity Building: Engaging the nonprofit and philanthropic communities in order to provide support to agencies. • Investing: Developing and implementing grant funds for nonprofits that are addressing the service gap for Chapel Hill and Carrboro youth. d) Agency's History with Providing These Services: Youth Forward provides a website, which has a resource directory currently listing over 100 area youth-serving organizations. Whether it's through the ConnectMe! App, the Youth Forward website, or community events, such as the annual Youth Providers Summit that brings together over 60 nonprofit leaders to discuss how to improve services for youth in the community, Youth Forward provides tools that connect not only youth to nonprofits, but nonprofits to one another. 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?) In December 2016, Youth Forward hired its first part time staff member, a Communication Manager, to help update the website and launch the app in 2017. 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: 1 # of FTE - Paid Part-Time Positions: 1 # of Volunteers: 0 # of FTE -Volunteers:0 g) Living Wage Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? No If no, please explain. Because we have a fiscal agent in California, we were unaware of this certification. Agency Information 1/31/2017 3:02:18 PM Page 8 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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 requests/awards/totals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FY16-17 FY17-18 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro - Affordable Housing Rehabilitation 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 o Program Generated Revenue o Local Government Grants ■ Carrboro Human Services ■ Carrboro Other ■ Chapel Hill Human Services ■ Chapel Hill Other (DO NOT include CDBG funding here) ■ Orange County Human Services Agency Information 1/31/2017 3:02:18 PM Page 9 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION ■ 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 o Compensation o Rent & Utilities o Supplies & Equipment o Travel & Training o Other Expenses iii. Does your agency budget show a Surplus or Deficit? Small Surplus Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. We are working on building a Reserve for the organization, so we have created a line item during these fiscal years for a reserve. iv. What is your agency's fiscal year? January 2017-December 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/31/2017 3:02:18 PM Page 10 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: ConnectMe! Program Primary Contact and Title: Tabitha Blackwell, Protect Executive Director Telephone Number: (919) 960-1673 E-Mail: tblackwell(@chcyouth.org a) Indicate the type of Human Service Needs Priority, if program applicable: ❑ Priority Area #1: safety-net services for disadvantaged residents ❑ Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ❑ Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education Family Resources X X X Jobs/Jobs Training Food Transportation Other: Please specify c) Provide a bulleted list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. • The ConnectMe! App will highlight the youth serving organizations in the community. I will list their programs, services, service learning opportunities, and events for youth and parents to browse. • In addition, it will sync with Google Maps to indicate how to get to the location for the program, service, or event via Chapel Hill Public Transit, bike, walking, or car. • The ConnectMe! App was originally designed in partnership with a team of UNC students through an APPLES Service Learning Course. PROGRAM INFORMATION 1/31/2017 3:02:18 PM Page 11 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description (3 pages OR LESS) Please provide the following information about the proposed program: d) Summarize the program services proposed and how the program will address a Town/County priority/goal? While strives have been made in Chapel Hill to bridge the "digital divide," there are still many households throughout Orange County that do not have internet access at home. This disconnection makes it difficult for youth and parents to easily access the services they may need. Even though these youth and parents may not have internet, many of them do have smartphones or tablets that provide them access to apps. With this in mind, Youth Forward conceptualized and developed a free, intuitive app, ConnectMe!, that provides community members the ability to access information on youth programs near them and maps the easiest route to get there. Youth and their families would simply choose the activity they are interested in, the day(s) they are available, and instantly have all the resources they need to connect to that program. For your review, a beta version can be found at m.chcyouth.org via an iPhone or on the Google Play store via Android. Youth Forward is in the process of redesigning its website to better support the app and more fully integrate all of the services the organization provides, from capacity building trainings to grantmaking. Whereas the website already provides a resources directory, this would allow users to browse the services in the same way they could the app. 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. In the Community Needs Assessment, an area of improvement that was indicated was the need to increase the community engagement in community spaces. Youth Forward will be posting not only community events on ConnectMe!, but the many programs and services offered through both the Town of Chapel Hill and the Town of Carrboro. ConnectMe! could create a hub for families to gain access to various points of engagement within the community, whether it is through government services or nonprofit programming. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The target population for ConnectMe! are students and parents. Youth Forward will be build relationships with Family Specialist in the Chapel Hill/Carrboro School District to ensure families most in need know about the app, as well as the website. In Fall 2017, we will also be launching a focused marketing campaign to promote these resources to the community at large. We will be using our existing nonprofit partners to promote ConnectMe!, in addition to local businesses. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) PROGRAM INFORMATION 1/31/2017 3:02:18 PM Page 12 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Tabitha Blackwell, Youth Forward's Executive Director, has been working in the Chapel Hill and Carrboro community for the last four years and has developed relationships with many of the nonprofits and foundations in the community. She helped develop the beta of ConnectMe! in partnership with the APPLES students. As ConnectMe! in its initial phase has gained interest from other counties, such as Durham and Chatham, she has now hired Kallie Norton to focus on finalizing the app and fully launching it. Kallie was hired in 2017 as Youth Forward's Part Time Communication Manager. She has an extensive background in website redesigns and launches. She also has X years of experience in marketing and communication. As Youth Forward has seen interest from other areas to replicate this app, there is the desire to ensure the app is as successful as possible in the Chapel Hill/Carrboro area to provide a great base for expansion into other locations in Orange County and surrounding areas. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. The activities will be carried out between July 2017 and May 2018. By July 2017, the website, in which supports the app, will be completed and the app will be in the Apple Store. A formal launch community event will be planned for the beginning of the school year in Fall 2017. Youth Forward will be marketing the app and conducting outreach from Fall of 2017 to Spring 2018. 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) Orange County is a community rich in resources for youth, however, many services and programs go unused by those that need it the most because they are unaware that they exist. By funding and partnering with ConnectMe!, the Town of Chapel Hill and the Town of Carrboro will have the opportunity to connect its citizens to the programs and services they need most by leveraging the tools already supported by local nonprofits. Public foundations, such as Strowd Roses, the Oak Foundation, and Grable have already committed and supported the development of this website and app. The support of the Chapel Hill, Carrboro, and Orange County is crucial in creating a true hub of resources that can connect multiple sectors to meet the needs of all citizens. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. While Youth Forward has funds for a bulk of the development of the app, we want to ensure that funds are secured for launch and outreach to those that are search for youth programs and services. Full funding would allow us to strategically target disconnected youth and parents to ensure they are able to access the many programs and services in the community. Even though full funding would be appreciated, any funding from both the Towns and the County will provide an amazing show of support and partnership for the project. k) Include any other pertinent information. Additional Program Information PROGRAM INFORMATION 1/31/2017 3:02:18 PM Page 13 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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 28747 28747 Female 31578 31578 Total 0 60325 60325 Ethnicity African-American 9328 9328 American Indian or Alaska Native Asian 2835 2835 Caucasian 38279 38279 Native Hawaiian or other Pacific Islander Other: specify Multi-Cultural 4634 4634 Other: specify Hispanic 5249 5249 Total 0 60325 60325 Of the above, how many Hispanic/Latino 5249 5249 Of the above, how many non-Hispanic/Latino 55076 55076 Total 0 60325 60325 Age 0-5 years 3004 3004 6-18 years 12076 12076 19-50 years 33155 43155 51+ years 12090 12090 Total 0 60325 60325 Geographic Location Alamance County Chatham County Durham County Wake County Orange County Breakdown Chapel Hill Public Housing 3000 3000 Town of Chapel Hill (Non-Public Housing) 43434 43434 Town of Carrboro 13891 13891 Town of Hillsborough City of Mebane (Orange County) Orange County (Outside Municipalities) Total 0 60325 60325 PROGRAM INFORMATION 1/31/2017 3:02:18 PM P a g e 14 o f 1 8 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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 (�jpecific, _Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program ConnectMe! 1. Program Activity Make ConnectMe! available on Google Play and the Name Apple Store. Program Goal Have the ConnectMe! app fully launched by July 1 st and have at least 700 downloads in the first year. Performance Measures We will be tracking the download numbers from both Google Play and the Apple Store. Previous Year Program Results Current Year Estimated By the end of this year, we will have at least 300 Results downloads. Next Year Projected We are projected to have at least 700 downloads, given Results the number of student in the school district. 2. Program Activity Increase usage of the website's resources directory Name Program Goal Increase the number of resource directory unique visits and searches by 10% Performance Measures Will monitor Google Analytics on the monthly basis Previous Year Program We had 4,288 searches and 3,477 unique views Results Current Year Estimated We will have at least 4,500 searches and at least 3,800 Results unique views Next Year Projected We will have at least 4,800 searches and at least 4000 Results I unique views PROGRAM INFORMATION 1/31/2017 3:02:18 PM Page 15 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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 o Program Generated Revenue o Local Government Grants ■ Carrboro Human Services ■ Carrboro Other ■ Chapel Hill Human Services ■ Chapel Hill Other (DO NOT include CDBG funding here) ■ Orange County Human Services ■ Orange County Other (DO NOT Include HOME funding here) o Other Government Grants ■ Triangle United Way ■ State Government ■ Federal Government (CDBG/HOME/etc.) ■ Private Foundation Grants o 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. The largest part of the "Other Expenses" line item is graphic design and development cost. There is also the cost associated with training the 3. This program budget represents what percent of the agency budget? 25% 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 52500 47500 Total # of Individuals 60325 60325 Cost Per Individual $0.87 $0.79 PROGRAM INFORMATION 1/31/2017 3:02:18 PM Page 16 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: Youth Forward Actual Estimated Projected Percent AGENCY REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ - $ - $ - 0 Agency Generated Revenue (fees) $ - $ - $ - 0 Local Government Grants: Human Services -Town of Carrboro $ - $ - $ 5,000 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services -Town of Chapel Hill $ - $ - $ 10,000 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services - Orange County . $ - $ - $ 5,000 0 Other- Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ 168,580.00 $ 197,823.00 $ 240,338.00 $ 0.21 Other Revenue $ 1,000 $ 1,000 $ 1,000 $ - Total Agency Revenue $ 169,580 $ 198,823 $ 261,338 31% AGENCY EXPENSES 0 Compensation $ 72,772 $ 85,223 $ 113,102 33% Rent& Utilities $ - $ - $ - 0 Supplies & Equipment $ 700 $ 715 $ 1,100 54% Travel &Training $ 500 $ 1,000 $ 3,000 200% Other Expenses: $ 94,746 $ 110,629 $ 143,069 1 29% Total Agency Expenses $ 168,718 $ 197,567 1 $ 260,271 1 32% 11 SURPLUS/(DEFICIT) FOR PERIOD: $ 862 1 $ 1,2561 $ 1,067 1 -15% FY 2015-16 Comparative Agency Budget Revised 9/29/2014 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME ConnectMe! Actual Estimated Projected Percent PROGRAM REVENUE 2015-16 2016-17 2017-18 Change Private Donations $ - $ - $ - 0 Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ - $ 5,000 $ - -100% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ 10,000 $ - -100% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services - Orange County $ - $ 5,000 $ - -100% Other- Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - 1 $ - 1 $ - 0 Other Government Grants Triangle United Way $ - $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBG/HOME/etc.) $ - $ - $ - 0 Private Foundation Grants $ - $ - $ - 0 Other Revenue $ - $ - $ - 0 Total Program Revenue $ - $ 20,000 $ - -100% PROGRAM EXPENSES Compensation $ - $ - $ - 0 Rent& Utilities $ - $ - $ - 0 Supplies & Equipment $ - $ - $ - 0 Travel &Training $ - $ - $ - 0 Other Expenses: $ - $ - $ - 0 Total Program Expenses $ I $ - 1 $ - 0 SURPLUS/(DEFICIT) FOR PERIOD: $ 1 $ 20,000 1 $ - 1 -100% DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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 Liability 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 1 —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 1/31/2017 3:02:18 PM Page 17 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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 BID $500,000 BID limit $500,000 for BID limit limit Commercial $100,000 Property General Liability Damage Liability $1 million Each $1,000,000 Bodily $1 million Each Occurrence Occurrence Injury and Property $2 million Aggregate � ry p y $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 1/31/2017 3:02:18 PM Page 18 of 18 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 EXHIBIT"B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: Tides Center Program Name: Youth Forward Funding Award: $750 Outline how the agency will spend Orange County's funding award. Expense Description Amount Communication Manager Salary $750 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • ConnectMe! App: Launch and Market the app to Orange County youth, parents, and community members. 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 Percentage of Orange County Schools provide outreach 75% Downloads of Orange County youth,parents,or community members on the Apple Store or 200 Google Play IO_ocuSigned by: 155 0Li UW 12/7/2017 Certified by: _ aa5F4so...5B424... Title: CEO Date: (Provider's Signature) DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 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. QocuSigned by: SS �t IUC.Y 12/7/2017 Certified by: ..... 9ED5B424... Title: CEO Date: (Provider's Signature) (Tides Center) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7117 DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 TIDES V IIGIIITr• J 1 DATE(MM/DD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 7/24/2017 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 NAME:ACT Felicia McAroy Marsh & McLennan Agency LLC PHON FAX A/C Ext:925 482-9300 A/C,No): 925 482-9390 Marsh & McLennan Ins Agency LLC E-MAIL SS, felicia.mcaroy@barneyandbarney.com 1340 Treat Blvd#250 Lic OH18131 INSURER(S)AFFORDING COVERAGE NAIC# Walnut Creek,CA 94597 INSURER A:Philadelphia Indemnity Ins. 18058 INSURED INSURER B:Tokio Marine Specialty Ins. 23850 Tides Center CHCYF,#1112 INSURER C:Berkshire Hathaway Homestate Co 20044 P.O. Box 29198 INSURER D: San Francisco,CA 94129 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY MM/DD/YY A X COMMERCIAL GENERAL LIABILITY PHPK1583250 12/01/2016 12/01/2017 EACHOCCURRENCE $1000000 CLAIMS-MADE �OCCUR PREMISES(Ea RENTED ) $1,000,000 MED EXP(Any one person) s20,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY F_]ECOT LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY PHPK1583250 2/01/2016 12/01/201 EOa aocideD SINGLE LIMIT 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ B UMBRELLA LIAB OCCUR PUB565168 2/01/2016 12/01/2017 EACH OCCURRENCE $10 000 000 X EXCESS LIAB X CLAIMS-MADE AGGREGATE $1 O 000 000 DIED I X I RETENTION$10 000 $ C WORKERS COMPENSATION TIWC809821 1/01/2017 01/01/201 X PTAT TE OTH- AND EMPLOYERS'LIABILITYER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? ® N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Project: Chapel Hill -Carrboro Youth Forward,#1112. CERTIFICATE HOLDER CANCELLATION Orange Count Government SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Allen Coleman ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1331700/M1140872 MANN DocuSign Envelope ID:380F50AD-C98D-426B-80DC-9Al34EB8DA24 TIDES V IIGIIITr• J 1 DATE(MM/DD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 7/24/2017 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 NAME:ACT Felicia McAroy Marsh & McLennan Agency LLC PHONEo FAX (A/C Ext:925 482-9300 A/C,No): 925 482-9390 Marsh & McLennan Ins Agncy LLC E-MAIL SS, felicia.mcaroy@barneyandbarney.com 1340 Treat Blvd#250 Lic OH18131 INSURER(S)AFFORDING COVERAGE NAIC# Walnut Creek,CA 94597 INSURER A:Philadelphia Insurance Company 18058 INSURED INSURER B: Tides Center INSURER C: CHCYF,#1112 INSURER D P.O. Box 29198 San Francisco,CA 94129 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PREMISESOEa ocicur ence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO LOC PRODUCTS-COMP/OP AGG $ POLICY JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PRO PER DAMAGE $ NON-OWNED Per accident HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N TAT TE I E ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Blanket Business PHPK1583250 12/01/2016 12/01/201 $721,329 Limit Personal Property $5000 Deductible DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Project: Chapel Hill -Carrboro Youth Forward,#1112. CERTIFICATE HOLDER CANCELLATION Orange Count Government SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Allen Coleman ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 8181 Hillsborough, NC 27278 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1331701/M1019836 MANN