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HomeMy WebLinkAbout2017-720-E Finance - Table outside agency agreement DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE 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 TABLE, a not-for-profit corporation, located at 209 East Main Street, Carrboro,NC 27510 ("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 TABLE 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 8500 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 2125. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County's obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. (TABLE) Orange County Outside Agency Performance Agreement Revised 712017 Page I of 7 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE 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. (TABLE) Orange County Outside Agency Performance Agreement Page 2 of 10 Rev. 7117 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE 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. (TABLE) Orange County Outside Agency Performance Agreement Page 3 of 10 Rev. 7117 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE 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 TABLE provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (TABLE) Orange County Outside Agency Performance Agreement Page 4 of 10 Rev. 7117 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE County: Finance&Administrative Services Provider: TABLE Orange County 209 East Main Street Post Office Box 8181 Carrboro,NC 27510 Hillsborough,NC 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part,term or provision held to be invalid. 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 ""Doc��us'g"ea by: he Provider 1A75802D6E604CE... 1211112017 Date (TABLE) Orange County Outside Agency Performance Agreement Page 5 of 10 Rev. 7117 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE Fo)16f0637994B755E477 °QCUS'gnedby, County Government 6KAnjtr N*i&L St" 12/28/2017 ... Bonnie Hammersley, County Manager Date (TABLE) Orange County Outside Agency Performance Agreement Page 6 of 10 Rev. 7117 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION FOR OFFICE USE ONLY Agency TABLE Inc. Received By Programs) Weekend Meal Backpack Program Date/Time / Section Subsection 1. Cover Page a. ® Applicant Contact Information b. ® Funding Requests c. Z Signed Application Cover Page d. ZSigned Disclosure of Conflicts of Interest and Clause 2. Agency Information a. Z Agency's Years in operation b. ® Agency's Purpose/Mission c. Z 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. Z Description of Identified Need f. Description of Population to be Served g. Program Staffing, Capacity, & Expertise h. Program Implementation Timeline i. Z Value of Investment j. Z Impact of Reduced/No Allocation k. ® Other Pertinent Information I. Z Target Population/Beneficiary Chart m. ® Work Statement n. Z 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. Z NC Solicitation License d. ® IRS Federal Tax-Exemption Letter e. ® Certificate of Insurance f. ® List of Board of Directors g. Z Solid Waste Program Fee (SWPF)Verification Application Submittal Checklist 1/30/2017 4:15:08 PM Page 5 of 19 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 1. OVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: Table Ministries, Inc. Applicant Organization's Physical Address: 209 E. Main Street Carrboro 27510 as of 211117 (previously 205 W. Weaver Street, Carrboro, NC 27510) Applicant Organization's Mailing Address: Same Applicant Organization's Web Address: www.tablenc.orq Executive Director: Ashton Tippins Telephone Number: 919-636-4860 E-Mail: infoatablenc.orq Tax ID Number: 26-1471735 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 Food for Weekend Meal Backpack Program $7,500 $7,500 $7,500 $22,500 Partial payment of program staff $2,000 $2,000 $2,000 $6,000 Assistance with cost of new rental space(90% $2,000 $2,000 $2,000 $6,000 program) Program Equipment $500 $500 $500 $1,500 Totals �12,C�uC� 6 QP,,C, �1�a wo 5} fCcr 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. ' r Signature: Executive Director Date Signature: �86 rd Chairperson Date AGENCY INFORMATION 1/30/2017 4:15:08 PM DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE 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 ❑ Z a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ N 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? ❑ Z c) Current beneficiaries of the program for which funds are being requested? ❑ ® d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: _ L �"�1 '� �, `a t' `' tive Director Date xecu g Si nature: , 1n / r- ill I � -;1 17D i BQai hair erso V / Date AGENCY INFORMATION 1/30/2017 4:15:08 PM P a q e, 7 C f I DocuSign Envelope ID: D3ADCOFO-560B-45AA-A3EA-B65E3A3A06DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION TABLE feeding local hungry kids Agency Information Years in Operation, Date of Incorporation, Agency's Purpose/Mission, Types of Services the Agency Provides Joy MacVane and several UNC students founded TABLE nearly 10 years ago in November 2007 (incorporated on the 21s). Our founders recognized the prevalence of hungry children in the Chapel Hill-Carrboro area and noticed that there were no food assistance services for children. Our Mission is to bring together UNC college students and local community members to feed hungry children in Chapel Hill and Carrboro. TABLE has three goals: to provide weekly emergency food aid to local hungry children, to educate and expose our little ones to healthy foods and eating habits, and increase community awareness of local childhood hunger. TABLE is a 501(c)(3) non-profit organization that began feeding 12 local elementary school children in 2008 and has since expanded to provide healthy food to approximately 500 preschool, elementary, and middle school children each week. TABLE has four programs to support its mission and goals: 1) The Weekend Meal Backpack Program provides healthy non-perishables, local fresh produce and fresh milk to children that are at risk of hunger on weekends and school holidays 2) SnackChef exposes our children to fresh foods and teaches them how to make easy, healthy snacks at home 3) Summer TABLE provides healthy food to local kids for 8-10 weeks in the summer months 4) TABLE On the Go (our newest program) allows children the opportunity to visit local farms, farmer's markets, and community gardens so they may learn about healthy food, their community, and where their food comes from. Agency's History with Providing These Services: TABLE has been delivering emergency food to hungry children in Chapel Hill and Carrboro since spring of 2008. Below we have outlined our ten year commitment to providing healthy food to local kids: 2007: TABLE was incorporated in November. 2008: TABLE started delivering non-perishable food to 12 local elementary school children each week. 2010: TABLE began incorporating local produce every week into our bags of healthy food due to collaboration with Farmer Foodshare. 2013/2014 School Year: TABLE's Weekend Meal Backpack Program provided weekly emergency food aid to 226 local hungry children. That's over 3 tons of food each month! 2014/2015 School Year: TABLE expanded its programming to include kids in preschool, elementary school, and middle school (3 years - 14 years)! TABLE began to serve 400 kids each week in February 2015. DocuSign Envelope ID: D3ADCOFO-560B-45AA-A3EA-B65E3A3A06DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Fall 2015: TABLE began serving healthy food to 500 kids each week through our Weekend Meal Backpack Program! 2015/2016: TABLE receives data through surveys that kids are able to perform better in school and eat healthier due to the weekly food that TABLE provides. Additionally, in order to better impact kids, we seek food preferences of the children we serve. During our ten years, TABLE has the following track record of success: 1) Success in providing healthy food to local hungry children through our four programs. During the 2015/2016 school year, we expanded our participating children roster from 400 children to 500, and we distributed over 56 tons of healthy food to local kids through the WMBP. Our 2016 Summer Program (similar to WMBP) provided healthy food to 374 children each week. Our SnackChef Program currently provides healthy snacks to 350 children during the school year, teaching them how to make nutritious snacks, try new foods, and eat healthy while empowering them to teach others. 2) Success in connecting with the local community. In just ten years, TABLE has grown from a small volunteer team to a flourishing, well-respected community organization. Generous donations of funds and time demonstrate the confidence and trust of local businesses, schools, religious organizations, civic groups, and private foundations. 3) Success in transitioning from a brand new start up nonprofit to one that is sustainable, thriving and expanding. Since 2013, TABLE has hired new staff, more than doubled our services to local children, and still increased income annually in order to continue the growth of each of our programs. Other Pertinent Agency Information (Ex. Has the agency experienced any major changes in the past year? Is there a new Executive Director?Are there new initiatives?) TABLE moved from 205 W. Weaver Street in Carrboro to a new, larger location at 209 E. Main Street in Carrboro on February 1 st. This will allow us to feed additional children, increase partnerships with local businesses and organizations. We will be at this location for the next 24 months. DocuSign Envelope ID: D3ADCOFO-560B-45AA-A3EA-B65E3A3A06DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Description Summarize the program services proposed and how the program will address a Town/County priority/goal? The Weekend Meal Backpack Program (WMBP) is TABLE's school year hunger relief program for hungry children living in Chapel Hill and Carrboro, NC. Currently, 30% of kids in the Chapel Hill-Carrboro School System rely on free and subsidized school breakfasts and lunches during the week. Consequently, they often go hungry on weekends and school vacations when those free meals are not available. TABLE works to meet their need for emergency food during those times. At the end of each week, TABLE distributes fresh produce and healthy non-perishables to participating youngsters. Receiving this emergency food aid each week allows children to return to school Mondays not ravenous - but ready to learn. TABLE's WMBP primarily addresses the Town/County priority to improve health and nutrition of local kids by providing them with healthy non-perishables, produce, and fresh milk every single week. According to parents' responses to our spring 2016 survey, 89% of kids who received healthy food from TABLE for more than one year ate fruits and vegetables often, compared to 70% of new participants. Secondarily, however, it is evident that the WMBP directly addresses the other two Town/County priorities as well: 1) WMBP improves the opportunity for a good education for local kids because they are able to focus on their schoolwork instead of their grumbling bellies as well as miss fewer school days because of frequent sickness. According to parent responses in spring 2016, 28% of our kids likely performed better academically because of food they received from TABLE. This is new data from 2016 and we will continue to measure it annually. 2) WMBP serves as a safety-net for parents and families of children because it allows parents to put more of their funds toward other bills like rent, utilities, fuel or transportation, keeping them from falling further into poverty. Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. TABLE's hunger relief programs target food-insecure preschool, elementary, and middle school children living in Chapel Hill and Carrboro, NC. During the current 2016/2017 school year, the Chapel Hill-Carrboro School System let us know that 30.11% of children attending their schools were enrolled in the National School Lunch Program suggesting that nearly 1 in 3 local children are 1) at risk for hunger on weekends and other times of the year when schools meals are not available and 2) have limited access to fresh food because of expense and access issues. The breakdown of this statistic is as follows: • 32.10% of preschool and elementary schoolchildren • 25.93% of middle school students That's more than 2,300 kids that are likely going hungry on weekends and school holidays when they do not have access to their free school breakfasts and lunches. These kids are not simply at risk for being hungry on weekends, but they are at risk for low DocuSign Envelope ID: D3ADCOFO-560B-45AA-A3EA-B65E3A3A06DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION academic performance, inappropriate behavior, low self-esteem, and health problems. Kids cannot grow up to be successful, productive adults under these conditions. They MUST have their basic needs fulfilled before they even stand a chance of performing well in school, behaving appropriately, having strong relationships, and strong, healthy bodies. The growth, prosperity, and success of our towns and county depend fully on the growth and success of our children. Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? TABLE provides healthy food every week to preschool, elementary, and middle school children living in Chapel Hill and Carrboro. All children participating in our hunger relief programs live in local low-income communities. About 97% of the children we serve represent racial and ethnic minority populations. To reach local needy children, TABLE partners with 26 community organizations to provide healthy food to those kids through the WMBP. TABLE identifies the beneficiaries of our program by partnering with staff and faculty at our numerous partner locations. School social workers and after school staff help us identify children and families that are in need as well as distribute and gather permission forms. At public housing facilities, our staff and volunteers walk door-to-door to offer our services. At all of our locations, parents simply need to fill out a permission form for their child to receive healthy food every single week. Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) The Program Director of our WMBP graduated from UNC-CH in 2012 with her B.A. in Sociology. She served as a Volunteer Coordinator for UNC Hospitals preparing her for her work at TABLE. She has been serving as TABLE's Program Director since April 2013. Since that time she has grown the number of children served from 170 to 500 children weekly. Our Team Leaders lead volunteer shifts for all volunteers every week. Traditionally, they are trained individually by our Program Director. Starting in February 2017, all Team Leaders will undergo an orientation about TABLE, specifically, so they better understand TABLE's programs and goals, the kids we serve, and are able to speak knowledgeably about hunger in Chapel Hill, Carrboro, and Orange County. New Team Leaders will also undergo an individual training session about their volunteer shift. Additionally, we will have bi-annual or quarterly opportunities for our volunteers to attend an orientation to learn about hunger, TABLE, and how they can get involved in helping us feed kids! Describe the specific period over which the activities will be carried out and include an implementation timeline. Planning for our WMBP begins in mid-August. Delivery of food will be carried out from mid- September 2017 until the first week of June 2018. We will be delivering bags of healthy food to kids at their school, after school center, or apartment home every week. This program has been executed for nine years. We begin reaching out to new and current partner agencies in August/early September. By mid-September we make our first delivery. We continue to add new children to our roster and increase the number of children served throughout the school year. DocuSign Envelope ID: D3ADCOFO-560B-45AA-A3EA-B65E3A3A06DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 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) As progressive as our communities are, it is not permissible for even one child to go hungry when we have the resources that we do. How can we expect a child to perform well in school, relationships, and life if we are not providing them with the healthy food that they need? If we want our Towns and community members to flourish, then we must start ensuring that our kids have their basic nutritional needs met. Funding TABLE's WMBP is a good investment because our surveys show that kids are able to perform better in school and eat healthier due to their nutritional needs being met (see Town Priority question above and Work Statement Chart). As you all know, there is an achievement gap in our schools among racial minorities and Caucasian children. In addition to other challenges they may be experiencing, these kids may often be experiencing poverty and hunger. It is no surprise that 97% of children that TABLE serves represent racial and ethnic minority populations. In order to improve performance at school, certainly kids should receive equitable treatment in our schools, but we cannot overlook the requirement to fulfill their basic needs either. How many of us can perform well in anything when we are persistently hungry? How many of us can say we've experienced persistent hunger? Our children shouldn't have to experience persistent hunger either. Help us help our kids succeed! Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. Currently, there are more than 2,300 children in Chapel Hill-Carrboro City School that are on free/reduced school lunches. Many of these children have not been offered the opportunity to receive weekly nutritious food due to our funding capacity. If TABLE does not receive funding from the Towns and County, we will have to work harder to acquire additional funding and we may not be able to increase our capacity in 2017-2018 and in coming years to serve additional children in our communities. This may delay our goal to deliver healthy food to hungry children in northern Orange County, as well as provide nutrition education field trips and interactive classes. Include any other pertinent information. TABLE's long-term plan is to provide healthy food to every single child in Chapel Hill-Carrboro that is hungry. In the coming 1-4 years, we would love to focus on providing and/or partnering with other organizations to provide the children in Hillsborough, Mebane, Efland, and other surrounding communities with the healthy food they need. We recognize that there is a major need and that TABLE could make a difference for the children in the remainder of our County. But, we need the support of our local governments (as well as local individuals, organizations, and businesses) to be able to meet that goal sooner rather than later. The longer it takes for us to acquire program and operational funding, the longer kids have to wait to have full bellies, get good grades, have high self-esteem, be healthy, etc. Please stand alongside TABLE to provide healthy food to our community's children. We appreciate your consideration. DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE 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) Yes 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 FYI 6-17 FYI 7-18 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 Weekend Meal Backpack $4,000 $12,000 Town of Chapel Hill Program Weekend Meal Backpack $5,000 $12,000 Town of Carrboro Program Weekend Meal Backpack $5,000 $12,000 Orange County Program *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 Agency Information 1/30/2017 4:15:08 PM P a g e 9 of 19 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION ■ 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 (CDBGIHOMEIetc.) ■ 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? Surplus Is there a significant change? Please provide a brief explanation for Surplus or Deficit, and significant changes. Please see all comments explaining our surplus on our budget document. iv. What is your agency's fiscal year? September 1, 2016—August 31 , 2017 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/30/2017 4 15:08 PM N : r 1 0 i 19 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Weekend Meal Backpack Program Program Primary Contact and Title: Laura Dille Telephone Number: 919-636-4860 E-Mail: Idille@tablenc.org a) Indicate the type of Human Service Needs Priority, if program applicable: Priority areas explained in Program Description M Priority Area #1: safety-net services for disadvantaged residents ® Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ® Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) Program Category Youth Adult Elderly Disabled Public Housing Neighborhoods/Residents Affordable Housing Affordable Healthcare Education Family Resources Jobs/Jobs Training Food X X Transportation Other: Please specify Nutrition Education X c) Provide a bulleted list of other agencies, if any, with which your agency coordinatesicollaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. • McDougle Elementary School: Provide information/support to feed attending kids. • Frank Porter Graham Elementary School: Provide information/support to feed attending kids. • Ephesus Elementary School: Provide information/support to feed attending kids. • Estes Hills Elementary School: Provide information/support to feed attending kids. • Mary Scroggs Elementary School: Provide information/support to feed attending kids. • Rashkis Elementary School: Provide information/support to feed attending kids. • Seawell Elementary School: Provide information/support to feed attending kids. • Carrboro Elementary School: Provide information/support to feed attending kids. PROGRAM INFORMATION 1/30/2017 4:15:08 PM Page 11 of 19 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION • McDougle Middle School: Provide information/support to feed attending kids. • Culbreth Middle School: Provide information/support to feed attending kids. • Phillips Middle School: Provide information/support to feed attending kids. • Smith Middle School: Provide information/support to feed attending kids. • Mi Escuelita: Provide information/support to feed attending kids. • Chapel Hill-Carrboro City Schools Pre-K/Head Start Program: Provide information/support to feed attending kids. • Dobbins Hill Family Resource Center: Provide information/support to feed attending kids. • Town of Chapel Hill (Public Housing Facilities): Provide informationlsupport to feed attending kids. • El Centro Hispano: Provide information/support to feed attending kids. • Hargraves Community Center: Provide information/support to feed attending kids. • Communiversity: Provide information/support to feed attending kids. • Rogers-Eubanks Neighborhood Association: Provide information/support to feed attending kids. • Street Scene Teen Center: Provide information/support to feed attending kids. • Maple View Farms: Donate fresh milk every week to kids through WMBP. Also partnered to create a field trip opportunity for our kids. • Farmer Foodshare: Partner to provide purchased and donated fresh food to kids via WMBP. • Weaver Street Market: Help us raise funds/food for programs. Provide services for TABLE to purchase food for WMBP and Summer TABLE. • Food for the Summer: Help us to efficiently reach and serve additional children in the summer. Program Description (3 pages OR LESS) Answers d- k are attached 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? e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) PROGRAM INFORMATION 1/30/2017 4:15:08 PM P a g e 1 2 o f 1 9 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE 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, For the table below, there is a difference in numbers depending on the information requested. All of these questions are asked of our target population when they sign up their child to receive our services. Due to language barriers and other circumstances, not all participants answered every question, which accounts for the different numbers below. Program Target Population Demographics Actual Estimated Projected 2015-16 2016-17 2017-18 Gender Male 242 275 315 Female 254 275 315 Total 496 550 630 Ethnicity African-American 195 215 244 American Indian or Alaska Native 0 0 1 Asian 105 135 151 Caucasian 14 40 53 Native Hawaiian or other Pacific Islander 0 0 1 Other: Multiracial, Biracial, and Hispanic_ 147 160 180 Total 461 550 630 Of the above, how many Hispanic/Latino 127 130 155 Of the above, how many non-Hispanic/Latino 334 420 475 Total 461 550 630 Age 0-5 years 15 50 80 6-18 years 485 500 550 19-50 years 0 0 0 51+ years 0 0 0 Total 500 550 630 Geographic Location Alamance County 0 0 1 Chatham County 0 0 1 Durham County 3 5 5 Wake County 1 2 2 Orange County Breakdown Chapel Hill Public Housing 96 103 110 Town of Chapel Hill (Non-Public Housing) 281 292 300 Town of Carrboro 133 140 171 Town of Hillsborough 1 4 15 City of Mebane(Orange County) 1 4 15 Orange County(Outside Municipalities) 0 0 10 PROGRAM INFORMATION 1/30/2017 4:15:08 PM P a g e 1 4 o f 1 9 I' DocuSign Envelope ID: D3ADCOFO-560B-45AA-A3EA-B65E3A3A06DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Total 516 550 630 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(,2pecific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly✓disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 100 meals per day, Monday-Friday.) • Performance Measures describe how you will evaluate the degree in which you achieved the stated goals. (i.e. Will track the number of meals delivered each day.) • Actual Program Results use program results to indicate the actual measureable achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of 105 meals per day.) Work Statement Chart for Program Weekend Meal Backpack Program 1. Program Activity Name Feed Hungry Kids! Program Goal Partner with local schools, after school centers, non-profits, Town Housing Departments, etc. to provide food weekly to local kids through our Weekend Meal Backpack Program. Performance Measures TABLE maintains a Current Numbers Sheet of children we serve every single week. We will use this to determine how many kids are served. Previous Year Program Results Provided up to 504 kids with healthy food for 34 weeks of the school year, Current Year Estimated Results Provide up to 550 kids with healthy food 34+ weeks of the school year. Next Year Projected Results Provide at least 600 kids with healthy food 34+weeks of the school year. 2. Program Activity Name Encourage Healthy Eating Program Goal Partner with local fresh food providers and donors to incorporate more healthy food for our kids that they begin to enjoy eating. By 2020, we would like to include 50% produce every week for our kids. Performance Measures We track all food that we distributed by weight.To measure this goal, we simply have to compare the total weights of the produce and milk with the total weight of all bags distributed. Previous Year Program. Results Provided healthy food to kids we serve by distributing bags that include 30 percent produce. Current Year Estimated Results Distribute bags that include 35% produce Next Year Projected Results Distribute bags that include 40% produce 3. Program Activity Name Help Kids Succeed PROGRAM INFORMATION 1/30/2017 4:15:08 PM P a g e 1 5 o f 1 9 DocuSign Envelope ID: D3ADCOFO-560B-45AA-A3EA-B65E3A3A06DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION Program Goal Provide nutritious foods that kids need every week as well as reinforce health and academic habits using our Food for Thought Worksheets (academic and nutrition education worksheets that go home monthly with our kids). Performance Measures TABLE executes surveys every spring with parents of children that TABLE serves. Previous Year Program Results 73% of kids who received healthy food from TABLE for more than one year received good grades often, compared to 45% of new participants. This means that 28% of our kids likely performed better academically because of food they received from TABLE. This is new data we began gathering in 2016 and will continue to measure annually. Additionally, 89% of kids who received healthy food from TABLE for more than one year ate fruits and vegetables often, compared to 70% of new participants. Current Year Estimated Results 30% of kids experience some other academic, health, personal, physical, or social benefit as a result of receiving the nutrition they need every week Next Year Projected Results 35% of kids experience some other academic, health, personal, physical, or social benefit as a result of receiving the nutrition they need every week. 4. Program Activity Name Program Goal Performance Measures Previous Year Program Results Current Year Estimated Results Next Year Projected Results PROGRAM INFORMATION 1/30/2017 4:15:08 PM P a g e 1 6 o f 1 9 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE XHIBIT A PROVIDER'S OUTSIDE AGENCY APPLICATION n) Program Budget 1. Submit your program budget. You may complete the provided template (separate xls file) or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template). Program Budgets are required to define budget amounts for the previous program year, current program year, and next program year for the following categories: • Revenues 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. 3. This program budget represents what percent of the agency budget? Around 83% 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 $333,262.65 $434,063.93 $466,366.00 Total # of Individuals 500 kidslyear 550 kidslyear 600 kidslyear Cost Per Individual $666.53 $789.21 1 $777.28 PROGRAM INFORMATION 1/30/2017 4:15:08 PM P a g e 1 7 o f 1 9 DocuSign Envelope ID: D3ADCOFO-560B-45AA-A3EA-B65E3A3A06DE 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 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 1/30/2017 4:15:08 PM P a g e 1 8 o f 1 9 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE 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 COUNTX3 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 BIDZ $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 1 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 1/30/2017 4.15:08 PM Page 19 of 19 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE EXHIBIT"B" Scope of Services—FY 2017-18 Outside Agency Performance Agreement Agency Name: TABLE,Inc. Program Name: Weekend Meal Backpack Program Funding Award: $8,500 Outline how the agency will spend Orange County's funding award. Expense Description Amount Food for Weekend Meal Backpack Program(62.5%) $5,312.50 Partial payment of Program Staff 16.7% $1,419.50 Assistance with rent(16.7%) $1,419.50 Program Equipment(4.1%) $348.50 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2018. • Deliver healthy food to at least 600 kids for 34+weeks of the school year through our Weekend Meal Backpack Program. • Distribute bags of food that include 40%produce through our Weekend Meal Backpack Program. • Help kids succeed — 35% of kids should experience some other academic, health, personal, physical, or social benefit as a result of participating in our Weekend Meal Backpack Program. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Number of kids served per week(compared to 555 kids/week in 2016-2017) 600+ kids/week Percentage of produce and fresh milk distributed in all bags of food(compared to approximately 40% 35%of 555 weekly bags of food in 2016-2017) produce in distributed bags Percentage of kids experiencing some additional impact by participating in WMBP(compared to 35%of kids approximately 30%of 555 kids in 2016-2017) experience another impact DOCUSigned by: CS�610- IrIFFLVUS 12/11/2017 Executive Director 1A7589276EE304CE. Certified by: rvlt� �+ + Title: Executive Director Date: 7/11/17 (Provider's Si e) DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE 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. DocuuSigned.{by: a4ab �rL-V(,5 Executive Director 12/11/2017 Certified by: _ 1A75802D6E604CE... Title: Date: (Provider's Signature) (TABLE) Orange County Outside Agency Performance Agreement Page 10 of 10 Rev. 7117 DocuSign Envelope ID: D3ADCOFO-56OB-45AA-A3EA-B65E3A3AO6DE DATE(MM1DDIYYYY1 .�► o� CERTIFICATE OF LIABILITY INSURANCE 0 711 212 0 1 7 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME. Natasha Shaffner StatQFarm Johnny Spillman Jr State Farm PHONE 919-636-5848 FAX No 866-246 8819 �PJC.NO.Extl�- A 1208 Raleigh Rd E-MAIL natasha@spillmaninsurance.com A. DRESS: Chapel Hill,NC 27516 1NSURERl3}AFFC RDING COVERAGE NAIL# INSURERA: State Farm General Insurance Company 25151 INSURED INSURER@: - Table Ministries Inc. MNsuRERc 209 E.Main St. F.. uCarrboro,NC 27510 RER FRER€ 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 ADDL SUER POLICY fPP POLICY EXP LIMITS TYPE OF INSURANCE _ POLICY NUMBER MMN fDDIV'YYY _ COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 DA.. GE TO RENTED 300,000 CLAIMS-MADE OCCUR PREMISES Ea o nen� MED EXP(An ono rwn S 5,000 93-bc-a158-3 0210712017 0210712018 PERSONAL&AOV INJURY $ 1,000,000 GENERAL AGGREGATE S 2,{}QO,QeQ GEN'L AGGREGATE LIMIT APPLIES PER' - PRO- PRODUCTS-COMPIOPAGG $ 2,000,000 POLICY E JECT ❑LOC S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S Ea accident} ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(per accident) 5 AUTOS ONLY AUTOS PROPERTY DA7ulAGE S HIRED NON-OWNED fPer accident) AUTOS ONLY AUTOS ONLY -- S EACH OCCURRENCE s UM@RELLA LIAR 'OCCUR EXCESS LIAR CLAIMS-h1ArlE AGGREGATE _ $ $ DFD RETENTIONS PER OTHI- 'WO R KE RS CO M PENSATION I STATUTE !AND EMPLOYERS"LIABILITY ANY PROPRER� fETORIPARTNERIEXECUTIVE Y E-L-EACH ACCIDENT $ OFFICIMEMBER EEXCLUDED? NIA E.L.01SEASE-EA EMPLOYE (Mandatary In INN . If yeG,desuibe under E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS below L I DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERE❑ IN ACCORDANCE WITH THE POLICY PROVISIONS. Orange County 200 South Cameron St. AUTHORt VE Hillsborough,NC 27278 Q 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORt] 1007486 732849.12 03.76.21118