Loading...
HomeMy WebLinkAbout2018-752-E Finance - The Arc of the Triangle outside agency agreement DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF OUTSIDE AGENCY AND CARDINAL MANAGED CARE FUNDS PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2018, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and The Arc of the Triangle, a not-for-profit corporation, located at 1709 Legion Road, Suite 100, Chapel Hill,NC 27514("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners. NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth,the County and The Arc of the Triangle agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2018 to June 30, 2019. 2. Scope of Services. a. Provider will provide services to the residents of Orange County, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit "A" AND the Cardinal Managed Funds Work Statement and any amendments or revisions thereto which is attached as Exhibit B, both of which are incorporated by reference. The Scope of Services and the Program Budgets 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. 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. Outside Agency Funding. i. Outside Agency Funding. The County agrees to appropriate funds for the provision of services described in Exhibit A, Scope of Services and may be more particularly described in the Revised Program Budget in Exhibit C, the maximum sum of 6,608 in Outside Agency Funds. ii. The Provider shall be paid Outside Agency Funds in four equal installments in the amount of 1,652. 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. b. Cardinal Managed Care Funding. (The Arc of the Triangle) Orange County Outside Agency and Cardinal Managed Care Fund Performance Agreement Revised 812018 Page I of 9 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF i. Cardinal Managed Care Funding. The County agrees to appropriate funds for the provision of services described in Exhibit B,Work Statement and may be more particularly described in the Revised Program Budget in Exhibit D,the maximum sum of 33,320in Cardinal Managed Care Funds. ii. The Provider shall be paid Cardinal Managed Care Funds in twelve equal monthly installments in the amount of 2,776.67. 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. c. All funds appropriated shall be used for purposes described in Exhibit A and 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 and Work Statement, at the discretion of the County the Provider may be required to repay the funds to the County. d. The County's obligation to make the payments is contingent upon receipt of Progress Reports and/or request for reimbursement as provided in Section 4 below, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services and Work Statement. e. Once Provider has satisfied its obligations as provided in Sections 3 and/or 4 payment will be made 21 days after receipt of the Progress Report or Request for Reimbursement. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Outside Agency Funds Reporting. Provider will provide Orange County a Quarterly Progress Report for Outside Agency funds that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 —December 31; January 1 —March 31 and April 1 -June 30. Reports are due on January 11,April 15, and July 8 of the program fiscal year. b. Cardinal Managed Funds Reporting. Provider will provide Orange County a Monthly Progress Report for Cardinal Managed Care funds that includes a fiscal report and updates on performance measures as outlined in the Work Statement. Progress Reports are due by the 15'h of the next month following the month being reported. c. 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: (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 2 of 9 Rev. 8118 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF 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 shall pay Provider that portion of the fees and expenses that it has earned to the date of termination, less any costs or expenses incurred or anticipated to be incurred by the County due to errors or omissions of the Provider. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County's remedies in law or in equity. c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. e. Should this Agreement be terminated, the Provider shall deliver to the County within seven (7) days, at no additional cost, all deliverables including any electronic data or files relating to the Project. £ Waiver. The payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. 6. Insurance. (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 3 of 9 Rev. 8118 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF 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 $t,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. 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 (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 4 of 9 Rev. 8118 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF 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. Limitation and Assignment. The County and the Provider each bind themselves, their successors, assigns and legal representatives to the terms of this Agreement. Neither the County nor the Provider shall assign or transfer its interest in this Agreement or the rights to payment to any other party without the written consent of the other. 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. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party,however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. 15. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County's living wage is $ 14.25 per hour. To the extent possible, Orange County recommends that The Arc of the Triangle provide a living wage to its employees. 16. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 5 of 9 Rev. 8118 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF County: Finance&Administrative Services Provider: The Arc of the Triangle Orange County 1709 Legion Road, Suite 100 Post Office Box 8181 Chapel Hill,NC 27514 Hillsborough,NC 27278 17. 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. 18. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part,term or provision held to be invalid. a. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. 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.FL DocuSignned by, n � �(Tye vi7 er rf ��a(f 11/20/2018 3703EC�A6A98489... Jennifer Pfaltzgraff,Executive Director Date F Docusignedby, re County Government ?6w it, h*kt.yS� 11/26/2018 0637994B755E477... Bonnie Hammersley, County Manager Date (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 6 of 9 Rev. 8118 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 1. COVER PAGE a) Applicant Contact Information Applicant Organization's Legal Name: The Arc of the Triangle Inc. Applicant Organization's Physical Address: 1709 Legion Rd, Suite 100, Chapel Hill NC 27517 Applicant Organization's Mailing Address: same Applicant Organization's Web Address: www.arctriangle.org Executive Director: Executive Director, Jennifer Pfaltzqraff Telephone Number: 919 942 5119 ext 117 E-Mail: jpfaltzgraff arctriangle.org Tax ID Number: 56-1214133 b) Funding Request List all FY18-19 Human Services (HS) Funding Being Requested — For All Programs) and the Proposed Use of Funds (2-3 lines or less) Program Carrboro Chapel Orange Total -HS Hill -HS Coun -HS Ex. Youth Afterschool Program $10,000 $15,000 $5,000 $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects Community Programs Individual Services for $7,500.00 $12,000.00 $7,500.00 $27,000.00 individuals with intellectual and developmental disabilities [I/DD] supplies, materials, salary, rent, printing, marketing. Totals $7,500.00 $12,000.00 $7,500.00 $27,000.00 c) To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. i Signature: L/--a'=)J'/ E-Abulive Director Date Signature: ��/ //Z.2/l-Y Board Chair p rson Date AGENCY INFORMATION 1/20/2018 3:58:40 PM Page 8 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates. YES NO ❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® c) Current beneficiaries of the program for which funds are being requested? ❑ ® d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. l Signature: E c e Director Date Signature: //O-�� I r Board Chairper n Date AGENCY INFORMATION 1/20/2018 3:58:40 PM Page 9 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT 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 (MonthlYear): 39 Years; 12/1979 b) Agency's Purpose/Mission (no more than a few sentences): The Arc of the Triangle supports children and adults with intellectual and developmental disabilities [I/DD] in the achievement of their personal goals and dreams in our community through partnership and advocacy. c) Types of Services the Agency Provides (bullet format): • Individual Services provides community and in-home based support services offers to individuals with I/DD. The Arc hires, trains and supervises direct care staff. Services are based on individual need. • Supported Employment provides support to adults looking for permanent employment in the community. Services include assessment, job development, coaching, intensive training, and long-term follow along. • Respite provides the family and primary caregivers with relief from caring for a loved one. • Community Programs based in Orange County: Community Connections Partner Program, Triangle Self-Advocacy Network, HOPE Gardens, HOOPs basketball, Petals with a Purpose, Cooking & Nutrition Class, and Friday Fun Day. d) Agency's History with Providing These Services: The Arc of Orange County formed thirty-nine years ago to serve individuals with Intellectual and Developmental Disabilities (I/DD) living in Orange County, North Carolina by parents of children with special needs. Where no other similar agencies existed, The Arc identified the need to provide families with programs, support and advocacy. Through the success of these programs The Arc expanded to include Supported Employment and community programs. In July 2014, The Arc of Orange County, merged with our Durham and Wake chapters, forming The Arc of the Triangle. The Arc of the Triangle proudly serves the Triangle area with a myriad of services, programs and events for the I/DD community. e) Other Pertinent Agency Information In December 2017, the Interim Executive Director was given the permanent position of Executive Director. In December our Assistant Director of Volunteer Services, Susan Chandler resigned. For years Susan was the heart behind our Orange County community programs. We are currently hiring her replacement. The new job title will be Outreach and Volunteer Specialist. Temporarily our Community Programs Director Michelle Foy is overseeing our Orange community programs. 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: 27 # of FTE - Paid Part-Time Positions: 57.5 #of Volunteers: 40 #of FTE -Volunteers: 4.24 Agency Information 1/20/2018 3:58:40 PM Page 10 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION g) Living Wage Does this agency pay permanent employees a minimum living wage? (YeslNo) NO If yes, is this agency an Orange County Living Wage Certified Employer? If no, please explain. We pay above the state mandated minimum wage to our part-time direct care staff, but we do not meet Orange County's living wage standard. Our reimbursement rate from the Managed Care Organizations (MCOs) who control Medicaid funding for I/DD services are not reimbursed at a rate high enough to pay a living wage. Where other agencies have discontinued these services, The Arc feels morally and professionally responsible to continue to provide services to the I/DD community and provide other employee incentives while someone works as direct care staff for The Arc: raises based on performance, Appreciation Week, bonuses for referring new staff, Employee of the Quarter which comes with recognition and a financial reward, acknowledgment of anniversaries with tokens of appreciation. It should also be noted that a large percentage of our employees in Orange County are college students who are fortunate enough to want to do this type of work because it is so rewarding and educational or for the experience, not the pay. h) Agency Budget i. Is your agency currently receiving and/or requesting other(non-Human Services) local (Town of Carrboro, Town of Chapel Hill, Orange County) government funding? (YeslNo) NO If yes, please list below: Include all programs that have funding requestslawardsltotals from Carrboro, Chapel Hill, and Orange County governments (other than Human Services). DO NOT include federal funding sources, such as CDBG and HOME. Program FYI 7-18 FYI 8-19 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 n/a *Add rows or attach additional page, if needed. Agency Information 1/20/2018 3:58:40 PM Page 11 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Agency Budget Operating Budget for Entire Agency AGENCY NAME: The Arc of the Triangle Community Programs and Individual Services AGENCY REVENUE Actual 2016-17 Estimated 2017-18 Projected 2018-19 Percent Change Private Donations $ 14,678.00 $ 60,000 $ 75,000 25% Agency Generated Revenue(fees) $ 2.988 880.00 $ 3,200,000 $ 3,500,000 9% Local Government Grants: Human Services-Town of Carrboro $ 6,u0-u.0-u $ b,uuu $ 7,500 25% Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ 6,000 $ 12,000 100% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 3,000.00 $ 6,450 $ 7,500 16% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ 0 Other Government Grants Triangle United Way $ 940.00 S 1,000.00 $ 1,000.00 $ - State Government 1 $ 155,000,00 S 975,000.00 $ 195.000.00 $ 0.11 Federal Government(CDBG/HOME/etc.) $ 74 476.00 S 75 000,00 $ 75.000,00 S - Private Foundation Grants $ 50.272.00 S 50.000.00 $ 75,000.00 $ D. Other Revenue $ 29.105.00 S 30,000 $ 30.000 5 - Total Agency Revenue $ 3,322,351.00 $ 3,609,460 $ 3,978,000 10% AGENCY EXPENSES Compensation $ 2,978,992.00 $ 3,100,000 $ 3,300,000 6% Rent&Utilities $ 100,183.00 $ 110,000 $ 120,000 9% Supplies&Equipment $ 62,732.00 $ 60,000 $ 60,000 0% Travel&Training $ 115 504.00 $ 110,000 $ 110,000 0% Other Expenses: $ 264.645.00 $ 220,000 $ 230.000 5% Total Agency Expenses $ 3,522,056.00 $ 3,600,000 $ 3,820,000 6% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ (199,705.00)1 $ 9,450 $ 158,000 1 1572% FY 2018-19 Agency Budget DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 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 ■ 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? Surplus Is there a significant change? Yes/No yes Please provide a brief explanation for Surplus or Deficit, and significant changes. 2016-17 was another challenging year for The Arc. The last several months the executive director spent cutting expenses in the areas of administrative salaries, mileage, and general office expenses to put them in line with our income. 2017-18 is proving that these changes are working. As of November 2017 our financial statement shows our Net Income as a positive figure. We are also seeing a growth in income from our individual services in Wake and Durham counties. iv. What is your agency's fiscal year? July 1, 2017 through June 30, 2018 (Example: July 1, 2016 through June 30, 2017) Agency Information 1/20/2018 3:58:40 PM Page 12 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: The Arc of the Triangle Community Programs and Individual Services Program Primary Contact and Title: Jennifer Pfaltzgraff, Executive Director Telephone Number: 919 942-5119 x117 E-Mail: jpfaltzgraff(a_arctriangle.org a) Indicate the type of Human Service Needs Priority, if program applicable: ® Priority Area #1: safety-net services for disadvantaged residents ® Priority Area #2: education, mentorship, and afterschool programming for youth facing a variety of challenges ® Priority Area #3: programs aimed at improving health and nutrition of needy residents b) Indicate the type of program for which you are requesting funding (Check all that apply to this program) c) P Program Category Youth Adult Elderly Disabled Public Housing r Neighborhoods/Residents o Affordable Housing v Affordable Healthcare d Education X e Family Resources X a Jobs/Jobs Training X b Food X u Transportation II Other: Please specify e t ed list of other agencies, if any, with which your agency coordinates/collaborates to accomplish or enhance the Projected Results in the Program(s) to be funded. For each, briefly describe the coordinated/collaborative efforts. • The North Carolina Division of Vocational Rehabilitation (VR) - persons recommended to The Arc from VR find gainful work with Arc Supported Employment Specialists. • Cardinal Innovations Health Care Solutions- families and individuals are recommended to The Arc to receive Home and Community Support, Respite Care, Supported Employment, Social and Volunteer opportunities. • Meals on Wheels (MOW)—Arc participants volunteer weekly delivering and preparing meals for Chapel Hill and Carrboro Meals on Wheels recipients. Once a month the Arc's cooking class bakes and donates thirty-six desserts to local MOW recipients. • Whole Foods — donates hundreds of beautiful fresh flowers every Wednesday for the Petals with a Purpose program. • Extraordinary Ventures (EV) — Arc participants are hired and employed at EV for a variety of jobs including Office Solutions, EV Laundry, EV Candle making, EV Pet sitting, as well as partnering in Friday Night Live a weekly evening at EV for friendship and fun for teens and adults with or without intellectual/developmental disabilities. • EZ Rider and Public Transportation —Arc participants use the free public bus system to access the community for their employment, education and social activities. PROGRAM INFORMATION 1/20/2018 3:58:40 PM Page 13 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION • The Seymour Senior Center — Arc participants volunteer weekly at the Seymour Center assisting and creating friendships with senior citizens, The Arc's Petals with a Purpose program also supplies monthly lunch bouquets honoring senior birthdays that month. • RSVP (Retired Seniors Volunteer Program) — senior citizen's volunteer with The Arc's social programs such as Petals with a Purpose and Spin class. • UNC Wellness Center Meadowmont HOOPs basketball meet weekly at the health club at no charge to The Arc. • The Chapel Hill Carrboro Chamber of Commerce — each fall the Chamber sponsors one Arc employee to participate in the Chapel Hill Carrboro Chamber's Leadership Series. • The Hillsborough Chamber of Commerce — Arc staff speaks biannually to educate and encourage Hillsborough residents to utilize Arc services and programs. • Sororities and Fraternities at UNC (APO, ZTA, Phi Beta Chi, and PKP) Arc's volunteer programs are comprised of a large percentage of sorority and fraternity students. Students organize major fundraisers for the benefit of The Arc (Tar Heel 10 Miler, ZTA Race for the Cure.) • The Knights of Columbus — raise awareness and funding for The Arc's programs through the LAMB's Tootsie Roll event each year. • The Cardinal Track Club — The Arc is chosen as one of the local non-profits to benefit from the awareness and the money raised from these three annual races: Annual "Turkey Gallop and Gorge," "Four on the Fourth," and Tour de Carrboro in October. • PNC Bank, Chapel Hill — each Wednesday the Petals with a Purpose program gathers in a PNC conference room at no charge to The Arc. • Hargraves Community Center — on Tuesdays Hargraves hosts The Arc's health and wellness cooking class allowing us to use the center at no charge. • The Root Cellar — encourages their staff to volunteer at The Arc. Each week the Petals with a Purpose program donates flower bouquets with Arc's information on each vase. The vases are displayed on their tables so patrons of the restaurant can learn about The Arc, take home and enjoy a free flower vase compliments of The Arc's "Acts of Random Compassion" Petals with a Purpose Program. People seeing these vases have contacted us to become volunteers with the Petals program. Just today we received a call from a film making student that wants to do a documentary on the Petals Program after witnessing the delivery of vases to the Root Cellar and the joy that it brought to many. • HOPE Gardens (Homeless Outreach Poverty Eradication program) - UNC School of Justice students converted an unused fourteen-acre piece of land into community gardens and offered local non-profits small garden beds to rent to grow vegetables, herbs, fruits, and flowers of their choosing. For the past six years, The Arc has rented two of these garden beds, growing food for cooking class and planting flowers to use in the Petals with a Purpose program. Surplus of the food we grow goes home with our individuals, or is donated to the local food pantry at St. Joseph's Church Food Pantry and to the Senior Center. The cooking class goes to the garden so individuals can learn firsthand how to grow organic food, make healthier food choices, and be in a peaceful setting enjoying the outdoors. • UNC School of Journalism and Public Relations — students intern thirty hours each semester creating videos, website, blogs, and marketing materials for The Arc. They also participate in The Arc's Spin, HOOPs basketball and cooking classes. • St. Joseph's Church in Carrboro - each week the Petals with a Purpose program donates two dozen flower vases for the St. Joseph's food pantry, so that recipients combine gifts of beauty to nourish their souls along with food to nourish their bodies. Several years ago, one of the food pantry patrons took home a Petals with a Purpose flower vase with Arc's information on it, contacted us and is now working as an Arc Direct Care Staff. The Petals program led this person to find employment at The Arc and to be in a position of giving back to the community. PROGRAM INFORMATION 1/20/2018 3:58:40 PM Page 14 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT 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? People with intellectual and developmental disabilities (I/DD) often lead lives that have limited opportunities for social inclusion and participation. Restricted and sedentary lifestyles significantly reduce the quality of life. Funding for these programs will go directly to coordinate and monitor activities that enable people with I/DD to become engaged with the community through the use of community volunteers, spaces and resources. This is consistent with the Chapel Hill, Carrboro and Orange County town goals of Creating a Place for Everyone and Nurturing Our Community. Community programs are important for teens and adults with I/DD because there are fewer opportunities once adults age out of the school system. Furthermore, people with I/DD have statistically higher rates of unemployment as well as limited choices in continuing education. Individuals with I/DD can and should be contributing members of the community in all aspects of their lives. Our community programs help to meet those needs. The Arc's community programs, supported employment and individual services have many components that are educational, social, and community driven in nature demonstrating that healthy lives are happy lives and happy lives are purposeful lives. Our community programs (Community Connections Partnership Program, Triangle Self-Advocacy Network, Cooking & Nutrition Class, HOOPs basketball, and Petals with a Purpose) are staffed by volunteers allowing the programs to be cost effective. Not having to pay for an instructor or teacher to lead our programs considerably cuts down on the cost of the programs, not to mention showcasing and using the talented, creative and enthusiastic local neighborhood volunteers who contribute to making our community a better place for everyone. An important by-product of our participants enjoying and being seen in the community as capable and contributing members of society is that our community's perception of a person with I/DD is elevated and changed for the better. This results in forming positive impressions and mutually beneficial relationships with the community. By educating the business community when there is a job opening or a volunteer opportunity these opportunities are equally extended to someone with a disability as would be their typical peer. This builds stronger communities, fosters equality, and diminishes bullying and prejudices. Community Connections is a program that matches a volunteer from our community with a participant (teen or adult with I/DD). The volunteer and participant spend time together each month, enjoying recreational and leisure activities. This is a time to learn new skills, grow as individuals, and to get to know each other as the partner becomes more socially involved in the community. Cooking & Nutrition Class teaches culinary skills in a hands-on kitchen setting. It encourages good nutrition choices and demonstrates working together as a team. In an effort to teach giving back to the community, once a month the class bakes and donates desserts to the local Meals on Wheels program. The recipes made in class are simple enough to be made at home allowing our individuals to lead healthier lives with better and proper nutrition once they leave the classroom. Arc HOOPS participants shoot some hoops, learn new skills, the rules of the game, get a good workout all while having fun. The coach's goal is to increase participation of women; grow the program by organizing teams and tournaments and create HOOPS uniforms. HOPE Community Gardens is a valuable and free food resource for individuals with I/DD. Arc participants and volunteers maintain the gardens and can bring home fresh organic food. Much of the food grown is delivered to local food pantries and to the senior center, so others in need in our community can enjoy eating locally grown food. Triangle Self Advocacy Network [TSAN] is a self-advocacy group that meets monthly. The group elects its own officers, contributes to the agenda, and handles most of its own responsibilities. Past topics of discussion have included fire safety, hurricane preparedness, relationships, finances, and planning group outings to the North Carolina State Fair. Petals with a Purpose participants, volunteers, and community partners gather together in the PROGRAM INFORMATION 1/20/2018 3:58:40 PM Page 15 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION community to create beautiful and unique flower vases. Recycled items destined for the landfill including soup cans and wine bottles are transformed into vases for flowers which are arranged by participants. Our local Whole Foods donates fresh flowers every week. The flower vases are then delivered into the community to places like St. Joseph's food pantry and the Seymour Senior Center, and to local events like the Special Olympics, Stroud Rose's Anniversary Celebration, and the Town of Chapel Hill's Annual Appreciation Luncheon. Recipients of the flower arrangements receive free gifts of beauty, learn about The Arc, and will continue to enjoy reusing the Petals with Purpose vase; all this with a focus to send less trash to our landfills. e) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment) to support the need for this program. The Arc programs meet multiple needs that are priorities for Chapel Hill, Carrboro, and Orange County. We provide educational and family resources for our participants through Cooking, Arc Hoops and TSAN. We teach civic engagement, Nurturing Our Community, by working together to create flower arrangements or food creations that are donated to other local nonprofit or governmental agencies. HOPE Community gardens offer a local place for our individuals to grow healthy food that they can take home, stretching their income by not having to pay for the food or the travel to other grocery stores. People with I/DD often live on limited budgets and organic, fresh food is often expensive and less accessible. Much of the food grown is also shared and donated to food pantries, Seymour Senior Center and Meals on Wheels, thereby providing more food to more people, and helping to nurture and feed our community in any small but meaningful way that we can. , Through our TSAN, our classes and Friday Fun Days, we provide happy, supported opportunities for vital socializing with both I/DD peers and the overall local community. Our Supported Employment program complement these activities by helping adults with I/DD get paying jobs in their community. We put a lot of effort into helping I/DD people become comfortable with using our local public transportation such as the free town bus systems and the UNC EZ Rider to get to and from programs. All these pieces come together to help Creating a Place for Everyone. f) Who is your target population of individuals to benefit from this program and how will they be identified and connected with the program? The Arc provides supports and services to more than three hundred adults and children with I/DD. People identified with I/DD are individuals that have autism, cerebral palsy, Down syndrome, Fragile X and a myriad of other diagnoses. Referrals for our services are made by individuals, the Dept. of Health and Human Services, MCOs, (Cardinal Innovations, Alliance Behavioral Healthcare), schools, and more. The Arc is among a network of agencies providing support and services to individuals in the community that is rapidly decreasing because of budget cuts, in spite of an increasing number of people needing our assistance. g) Describe the credentials of the program manager and other key staff. (Ex. Identify Program Manager and credentials, describe training provided to volunteers, etc.) Our Community Program Director, Michelle Foy holds her Bachelors in Fine Arts and Masters in Movement Therapy. She is also a certified C&I (Communications and Interaction Strategies) training instructor. C&I training focuses on healthy interactions with persons with I/DD. These trainings are given to all Arc paid staff and Arc volunteers in addition to the on-on-one training they currently receive. Arc staff that oversee participant caseloads are certified Qualified Professionals. h) Describe the specific period over which the activities will be carried out and include an implementation timeline. All community programs and individual services are offered year round. 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) Investing in an underserved, marginalized population is always a good idea. For over 60 years, The Arc PROGRAM INFORMATION 1/20/2018 3:58:40 PM Page 16 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION has been the voice for people with I/DD in United States. The 1950s were a time when most children with disabilities were ignored by society, and often institutionalized. Parents of these special kids got organized, formed The Arc in our area and began advocating to keep their children at home, send them to school, and to educate the community about what it means to have a disability. Arc families also took the lead on developing advocacy and awareness while supporting their own loved ones. Thus was born the largest grassroots movement to promote the rights of people with I/DD. Yet we still have a long way to go. In 2017 people still use the "R" word and think it is acceptable to bully and make fun of people with I/DD. Kids with special needs are not encouraged to socialize with their typical peers. It is still uncommon for an adult with I/DD to held a regular job, use public transportation and choose their activities. At The Arc we provide necessary supports so our participants can access their community and be active members of society. Everything we do is community based. Promoting inclusion wherever we can. The community programs of The Arc are an example of a community coming together: our participants, staff, volunteers, and community partners demonstrating a passion and sometimes empathy for our mission so we see the person, not the disability. j) Describe what would happen if requested funding is not awarded at all or if a reduced allocation is recommended. It has been shown that people live longer and have happier lives when they have friendships, good nutrition and exercise, purpose in their life, and social capital. When people lead isolated and lonely lives their health suffers and they are prone to more emergency room visits and costly medical care. The Arc believes in using our programs to proactively help people with I/DD lead happy, productive lives, so in the long run an ounce of prevention is worth more (and costs much less) than a pound of cure. If the requested funding amount is reduced or not awarded, we will not be able to serve as many people with these programs. k)What percentage of your target population is low-moderate income? 25% 1) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc.?) The Arc of the Triangle is a membership organization. Our members are invited to participate in our Annual Meeting, vote for our board of directors, participate in By-Law revisions and join committees (Program, Development, and Finance). The Arc sends out annual surveys to participants/families, volunteers and staff to collect data to ensure we offer quality programming and make changes as necessary. m) Include any other pertinent information. _ II ` - individual Services Triangle Self-Advocacy Network! HOPE Gardens L ` Arc HOOPS ( t F Cooking St Nutrition Class 3 Petals with a Purpose Community Connections Supported Employment PROGRAM INFORMATION 1/20/2018 3:58:40 PM Page 17 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Additional Program Information d) 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 2016-17 2017-18 2018-19 Gender Male 298 342 376 Female 144 166 200 Total 442 508 559 Ethnicity African-American 75 86 99 American Indian or Alaska Native 8 9 9 Asian 15 17 19 Caucasian 227 261 287 Native Hawaiian or other Pacific Islander Other: specify 117 135 148 Total 442 508 559 Of the above, how many Hispanic/Latino 14 16 18 Total 442 508 559 Age 0-5 years 6 7 8 6-18 years 96 110 120 19-50 years 293 337 371 51+ years 47 54 60 Total F 442 508 559 Geographic Location Alamance County 1 1 1 Chatham County 12 14 15 Durham County 15 17 25 Wake County 193 222 258 Orange County Breakdown Chapel Hill Public Housing Town of Chapel Hill (Non-Public Housing) 144 166 170 Town of Carrboro 15 17 18 Town of Hillsborough 18 21 21 City of Mebane (Orange County) 12 13 13 Orange County (Outside Municipalities) 32 37 38 Total 442 508 559 PROGRAM INFORMATION 1/20/2018 3:58:40 PM Page 18 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Work Statement e) Complete the Work Statement Chart to describe the work to be performed. This chart is used to document program activities, program goals, performance measures, and actual results. (Add more rows as needed) If this is a new program, you will only document the projected information. Every program is required to have AT LEAST 1 Program Activity, which should be SMART(Specific, Measurable, Achievable, Relevant, and Time-bound. Click on SMART Goals to learn more. • Program Activities should outline major activities the agency implements to accomplish its program goals. (i.e. Deliver meals to elderly/disabled residents.) • Program Goal should explain what the program is trying to achieve/accomplish. Goals are statements about what the program should accomplish. (i.e. Deliver 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 The Arc of the Triangle: Community Programs and Individual Services 1. Program Activity Name Petals with a Purpose and HOPE Community Gardens Program Goal Using a combination of Direct Care Staff and Volunteers, 25 individuals with I/DD will participate in non-segregated environments where individuals participate in civic minded and community activities such as the Petals with a Purpose program and volunteering at the HOPE gardens that give back to the community at large. Performance Measures Attendance records, participant annual surveys Previous Year Program Results Approximately 50 individuals were served in all of our community programs in the Orange County area, participated in Petals with a Purpose and HOPE Gardens. 171 individuals are served through Individual services in Orange County. Current Year Estimated Results Approximately 50 individuals were served in our community programs in the Orange County area. 185 individuals are served through Individual services in Orange County. Next Year Projected Results Out of approximately 185 individuals served Orange County, 25 or more will participate in Petals with a Purpose and HOPE Gardens. 2. Program Activity Name Community Connections Partner Program Program Goal 25 individuals with I/DD will participate regularly in community based social and recreational activities through the Community Connections program; volunteer partners will also increase to 25 Performance Measures Reports form the individual and partner as to times met, activities enjoyed, length of time met. Participant and Partner annual surveys. Previous Year Program Results Approximately 50 individuals were served in our community programs in the Orange County area. 185 individuals are served through Individual services in Orange County. 18 participants had a Communit Connections Partner. Current Year Estimated Results 20 participants Next Year Projected Results 30 participants will 130participate and have matches. At least 10 will be new to the program. PROGRAM INFORMATION 1/20/2018 3:58:40 PM Page 19 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 3. Program Activity Name Cooking and Nutrition Classes (Level I & II); Arc HOOPS; Friday Fun Day Program Goal Using a combination of paid Direct Support Professionals and Volunteers, sixty individuals with I/DD will learn about and participate in leading healthy lifestyles through good nutrition, exercise and social activities. This includes participation in Cooking and Nutrition Classes (Level I and 11), Friday Fun Day, and Arc HOOPs basketball. Performance Measures Attendance records, participant annual surveys Previous Year Program Results Approximately 50 individuals were served in our community programs in the Orange County area. 185 individuals are served through Individual services in Orange County. 35 people increased participated in Cooking and Nutrition Classes, Friday Fun Day, and Arc HOOPS basketball. Current Year Estimated Results 40 people increased their health by participating in Cooking Classes, Friday Fun Day, and Arc HOOPs basketball. Next Year Projected Results 75 people will learn more about the importance of exercise and movement, healthy lifestyles and good social choices by participating in Cooking and Nutrition Classes (Level I & II), Friday Fun Day. and Arc HOOPs. f) 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 PROGRAM INFORMATION 1/20/2018 3:58:40 PM Page 20 of 24 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION 2. Program Budget Detail — Provide description of "other" budget items, not defined. Advertising, printing, postage/shipping, IT/technology, telephone/internet, office equipment lease, office supplies 3. This program budget represents what percent of the agency budget? 7% 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 2016-17 Estimated 2017-18 Projected 2018-19 Total Cost of Program 87,328 78,165 73,140 Total #of Individuals 106 129 130 Cost Per Individual $824/yr $606/yr $563/yr PROGRAM INFORMATION 1/20/2018 3:58:40 PM Page 21 of 24 DocuSign Envelope ID:9F46lF1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION Program Budget Operating Budget for Program PROGRAM NAME: The Arc of the Triangle Community Program and Individual Services Actual 2016-17 Estimated 2017 Projected. Percent PROGRAM REVENUE 18 2018-19 Change Private Donations $ 309 $ 1,000 $ 2,000 100% Program Generated Revenue $ 1.896 $ 2.000 $ 2.500 25% Local Government Grants: Human Services-Town of Carrboro $ 6,000 $ 6,000 $ 7,500 251/0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ 6,000 $ 12,000 100% Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 3,000 $ 6,450 $ 7,500 16% Other-Orange County $ - $ - $ - 0 Other-Town of Hillsborough $ - $ - $ 0 Other Government Grants Triangle United Way , - $ - $ _ 0 State Government $ $ - $ _ 0 Federal Government(CDBG/HOME/etc.) $ 33,320.00 $ 33.320.00 $ 33,320.00 5 - Private Foundation Grants $ 7,500.00 $ 5,000.00 $ 7.500.00 $ 0.50 Other Revenue $ $ $ 0 Total Program Revenue $ 52,025 $ 59,770 $ 72,320E1% PROGRAM EXPENSES Compensation $ 67,400 $ 50,000 1 $ 45,000 -10% Rent&Utilities $ 7,012 $ 7,365 $ 7,740 5% Supplies&Equipment $ 4,391 $ 4,400 $ 4,400 0% Travel&Training $ 1,000 $ 1,000 0% Other Expenses: $ 18.525 $ 15.400 $ 15.000 -3%u Total Program Expenses $ 87,328 $ 78,165 $ 73,140 -60/ SURPLUS/(DEFICIT) FOR PERIOD: 1 $ (35,303) $ (18,395) $ (820) 96% FY 2018-19 Program Budget DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT B:CARDINAL MENTAL HEALTH APPLICATION FY2018-19 MENTAL HEALTH SERVICES APPLICATION a) Applicant Contact Information Applicant Organization's Legal Name: Institute of Art Therapy, Inc. (DBA: Art Therapy Institute) Applicant Organization's Physical Address: 200 N. Greensboro St., D-6 Carrboro, NC 27510 Applicant Organization's Mailing Address: 200 N. Greensboro St., D-6 Carrboro, INC 27510 Applicant Organization's Web Address: ncati.org Executive Director: Hillary Rubesin Telephone Number: 919-381-6068 E-Mail: hrubesin(a_)ncati.org Tax ID Number: 26-3447555 b) Funding Re uest Program Total Ex. Youth Afterschool Program $30,000 Afterschool Program Coordinator salary and materials for youth activities and projects Newcomers Art Therapy Program: Payment for $27,600 therapy services, cultural/clinical training and supervision, research and evaluation, and interpreter services. Totals $27,600 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: 8/29/2018 Executive&Jrector Date Signature. SVA� M T 08/29/2018 Board Chairperson Date AGENCY INFORMATION 8/28/2018 5.02.49 PM DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT B:CARDINAL MENTAL HEALTH 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? El E 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: 8/29/2018 Executi irector Date Signature: gm� M e� " 08/29/2018 Board Chairperson Date AGENCY INFORMATION 8/28/2018 5.02.49 PM Page 2 of 12 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT B:CARDINAL MENTAL HEALTH APPLICATION AGENCY INFORMATION Please provide the following information about your agency: a) Years in Operation, Date of Incorporation (Month/Year): September, 2009 b) Agency's Purpose/Mission (no more than a few sentences): The Art Therapy Institute (ATI) is an organization of mental health professionals dedicated to the healing power of the arts. We provide clinical art therapy services to diverse populations, empowering clients to develop their identities through the art-making process. We also offer training to allied professionals and seek to raise awareness in the general community about our profession and the benefits of arts-based therapy. c) Living Wage: Does this agency pay permanent employees a minimum living wage? (Yes/No) Yes If yes, is this agency an Orange County Living Waste Certified Employer? Yes If no, please explain. # of FTE - Full-Time Paid Positions: 3 # of FTE - Paid Part-Time Positions: 6 # of Volunteers: 116 # of FTE -Volunteers:1.5 Agency Information 8/28/2018 5:02:49 PM P a g e 3 o If 1 2 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT B:CARDINAL MENTAL HEALTH APPLICATION PROGRAM INFORMATION (Submit a separate Section 3 for each program) Program Name: Newcomer Art Therapy Program Program Primary Contact and Title: Hillary Rubesin, Executive Director Telephone Number: 610-348-7253 E-Mail: hrubesinCdQ_gmail.com Program Description (3 pages OR LESS) Please provide the following information about the proposed program: a) Describe the community need or problem to be addressed in relation to the Chapel Hill Human Services Needs Assessment, Orange County BOCC Goals and Priorities, Town of Chapel Hill Council Goals, Carrboro Board Priorities, or other community priorities (i.e. Council/Board Goals). Reference local data (using the provided links, i.e. Chapel Hill Human Services Needs Assessment)to support the need for this program. The Newcomer Art Therapy Program (NATP) began in response to a community needs assessment from UNC-Chapel Hill in 2008 and has expanded programming efforts and reach ever since. ATI's NATP directly addresses numerous town and county needs and priorities. AT] is committed to cultural sensitivity (Carrboro Board Priority A), social justice work, and the bridging of diverse cultures (Orange County overarching goals), through its ongoing efforts of cultural humility and cultural safety in counseling and research practices. These practices acknowledge the power dynamics inherent between community members of different cultures and positions, and commit to providing resources and settings that are familiar and empowering to historically disenfranchised communities. ATI's programming also relates to Chapel Hill's "Develop Good Places, New Spaces" initiative in that we bring creative arts and social programming to diverse communities, especially residents of the Northside neighborhood and the Rogers Road Habitat Housing development (where many of our clients reside). Our program also aligns with Chapel Hill's goal to "Create a Place for Everyone" through cultural arts engagement. ATI's art therapy program brings free, arts-based services to some of our county's most disadvantaged residents, who wouldn't normally have access to or know how to access these types of programs. Finally, data from the Chapel Hill Human Services Needs Assessment indicate that residents need affordable healthcare, education and family resources, and jobs and job training. ATI's NATP addresses all these needs in different ways. First and foremost, through grants, private donations, and Medicaid billing, we provide mental health services free of charge to newcomer clients. Our adult services, in particular, include "hybrid groups" focusing on health education, family education, and resource sharing. We also provide vocational support to high school students and newcomer adults. Finally, we hire newcomers to interpret, provide cultural trainings to staff members, and most recently, for billing/accounting support! b) 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 8/28/2018 5:02:49 PM P a g e 4 o f 1 2 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT B:CARDINAL MENTAL HEALTH APPLICATION ATI therapists all have Masters degrees in art therapy or related fields and are all fully licensed or working towards full licensure as professional counselors in NC. All clinicians receive weekly group supervision and individual supervision as needed, according to client load and level of licensure. ATI therapists and interns have a combined 50+ years of experience working with newcomers, and receive annual training in multicultural competencies. In addition to this extensive clinical experience and training, the ED holds a doctorate in expressive arts therapy, with dissertation research focused on refugee mental health. Research on newcomer programming is conducted in collaboration with various universities including UNC-Chapel Hill, UNC- Greensboro, Duke University, Lesley University, and other community-based agencies. c) What efforts do you make to seek feedback about your program from your target population (e.g. survey, evaluations, etc.?) Beyond the research evaluations ATI conducts every year to monitor the mental health and social functioning of our clients, ATI also surveys teachers, school staff, and newcomer clients about their experiences with the program. Finally, ATI also surveys community art show attendees who view the client artwork and stories to evaluate how the program impacts community perceptions of newcomers. PROGRAM INFORMATION 8/28/2018 5:02:49 PM Page 5 of 12 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT B:CARDINAL MENTAL HEALTH APPLICATION Additional Program Information d) 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 2016-17 2017-18 2018-19 Gender Male 126 125 130 Female 104 120 145 Total 230 245 275 Ethnicity African-American 5 5 American Indian or Alaska Native Asian 150 160 135 Caucasian Native Hawaiian or other Pacific Islander Other: specify 75 80 140 Total 230 245 275 Of the above, how many Hispanic/Latino 75 $0 100 Of the above, how many non-Hispanic/Latino 155 165 175 Total 230 245 275 Age 0-5 years 6-18 years 200 215 225 19-50 years 15 15 30 51+ years 15 15 20 Total 230 245 275 Geographic Location Alamance County Chatham County Durham County 50 50 75 Wake County Grange County Breakdown Chapel Hill Public Housing 30 35 50 Town of Chapel Hill (Non-Public Housing) $0 $5 110 Town of Carrboro 70 75 100 Town of Hillsborough City of Mebane (Orange County) 5 Orange County (Outside Municipalities) 10 Total 230 245 275 PROGRAM INFORMATION 8/28/2018 5:02:49 PM Page 6 of 12 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT B:CARDINAL MENTAL HEALTH APPLICATION Work Statement e) 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 1. Program Activity Name Clinical Therapy Services: Reach and Retention Program Goal With these funds, ATI will reach at least 30 newcomers in Orange County through both individual and group therapy services. (Served weekly or monthly throughout the year) Performance Measures Art therapy records of attendance Previous Year Program Results Cardinal's DFA was not evaluated last year. Current Year Estimated Results Cardinal's DFA was not evaluated this year. Next Year Projected Results At least 30 newcomer adults and children will be provided with weekly or monthly therapy services through this funding. 2. Program Activity Name Training and Supervision Program Goal All ATI clinicians and interns (10) will receive cultural training and clinical supervision as related to this project. (At least 3 hours of cultural training each, and at least 30 hours of supervision each) Performance Measures Records of hours of attendance in training and supervision Previous Year Program Results Cardinal's DFA was not evaluated last year. Current Year Estimated Results Cardinal's DFA was not evaluated last year. Next Year Projected Results 10 ATI clinicians and interns in the NATP program will receive training and supervision. (At least 3 hours of cultural training each, and at least 30 hours of supervision each 3. Program Activity Name Interpretation Program Goal ATI will hire interpreters to serve at least 75 newcomer clients during the 18-19 fiscal year. Performance Measures Record of number of newcomer clients served by interpreters Previous Year Program Results Cardinal's DFA was not evaluated last year. Current Year Estimated Results Cardinal's DFA was not evaluated last year. Next Year Projected Results 75 newcomers will receive interpreter services through ATI. 4. Program Activity Name Research and Evaluation PROGRAM INFORMATION 8/28/2018 5:02:49 PM P a g e 7 o DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT B:CARDINAL MENTAL HEALTH APPLICATION Program Goal ATI will conduct culturally-congruent research with over 100 newcomer clients in Orange County. Performance Measures Number of newcomers participating in quantitative and qualitative research protocols. Previous Year Program Results Cardinal's DFA was not evaluated last year. Current Year Estimated Results Cardinal's DFA was not evaluated last year. Next Year Projected Results Over 100 newcomers in Orange County will participate in ATI's research practices. Agency Budget (See Excel Spreadsheet) ATI's agency budget was provided for a previous grant. Orange County already has access to this document. i. Is your agency currently receiving and/or requesting other local government funding? (YeslNo) Yes, ATI requested the following amount from the county and towns last January for the NATP, and we were awarded the following amounts for the 18-19 fiscal year. If yes, please list below: Program FY18-19 FY18-19 Source Award Request Ex: Affordable Rental 0 $20,000 Carrboro - Affordable Housing Rehabilitation EX: Agency Administration $15,000 $15,000 Chapel Hill - Other Ex. Total $15,000 $35,000 Total Funding Newcomer Art Therapy Program $3555 $5,000 Orange County- Outside A enc (Human Services Funding Newcomer Art Therapy Program $3000 $15,000 Chapel Hill- Outside Agency/Human Services Funding Newcomer Art Therapy Program $6000 $10,000 Carrboro- Outside Agency/Human Services Funding TOTAL $12,555 $30,000 Total Funding "Add rows or attach additional page, if needed. ii. Submit your agency's budget. You may complete the provided template (separate xis 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). PROGRAM INFORMATION 8/28/2018 5:02:49 PM P a g e 8 o i 1 2 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT B:CARDINAL MENTAL HEALTH APPLICATION AT!'s agency budget was provided for a previous grant. Orange County already has access to this document. 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 c Private Donations o Program Generated Revenue o Local Government Grants ■ Carrboro Human Services ■ Carrboro Other • Chapel Hill Human Services ■ Chapel HIII 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 8. Utilities o Supplies & Equipment a Travel & Training a Other Expenses iii. Does your agency budget show a Surplus or Deficit? Surplus Is there a significant change? Yes/No No Please provide a brief explanation for Surplus or Deficit, and significant changes. ATI's budget for 2017 shows a surplus in spite of$27,000 in budget cuts, due to a major increase in fundraising efforts in the second half of 2017 to help offset unexpected financial losses. iv. What is your agency's fiscal year? Jan 1, 2018-Dec 31, 2018 (Example: July 1, 2016 through June 30, 2017) PROGRAM INFORMATION 8/28/2018 5:02:49 PM Page 9 of 12 DocuSign Envelope ID:9F46lF1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT"B" Scope of Services—FY 2018-19 Outside Agency Performance Agreement Agency Name: The Are of the Triangle,Inc. Program Name: Community Programs and Individual Services Funding Award: $6,608 Outline how the agency will spend Orange County's funding award. Expense Description Amount Staff Salary $3,000 Marketin and advertising expense $750 Materials and Supplies for programs $1,050 Insurance(Liability,Workers Comp, C ber,Abuse and Molestation) $1,g0g TOTAL$6,608 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2019. • Expand Community programs to Orange County citizens with disabilities not familiar with The Are. • Funding for these programs will go directly to coordinate and monitor activities that enable people with I/DD to become engaged with the community through the use of community volunteers, spaces and resources. This is consistent with the Chapel Hill, Carrboro and Orange County town goals of Creating a Place for Everyone and Nurturing Our Community. • Meet multiple needs that are priorities for Chapel Hill, Carrboro, and Orange County. Provide educational and family resources for our participants through Cooking, Arc Hoops and TSAN. Teach civic engagement, by working together to create flower arrangements or food creations that are donated to other local nonprofit or governmental agencies. • People with I/DD seen in the community as capable and contributing members of society. This forms positive impressions and mutually beneficial relationships with the community. By educating the business community when there is a job opening or a volunteer opportunity these opportunities are equally extended to someone with a disability as would be their typical peer. Build stronger communities, fosters equality, and diminishes bullying and prejudices. 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 descri tion or for an earlier oerformance measure. Performance Measures Anticipated Results Encourage inclusive and integrated programming with non-disabled peers(currently less than 5% 10°% of our participants are adults without disabilities)(60 participants with disabilities served now- increase we would like that ratio to improve so 90%are people with disabilities and a minimum of 10% are their typical peers) Total participation in Petals with a Purpose&HOPE Gardens for FY 18-19 25 Total participation in Triangle Self-Advocacy Network for FY 18-19 15 Total participation in Cooking&Nutrition Class;Are HOOPS; Friday Fun Day for FY 18-19 60 Total participation in Community Connections for FY 18-19 25 U0CU Sig ned by:133703ECDADA18491 �' PFW... , � /2018 Executive Director Certified by:rt�' �m_� Title:_ � TA 1- CDate: r: —'"f-4*10vider's S gnature) DocuSign Envelope ID:9F46lF1C-C86C-42DC-B78C-50FC18D204DF EXHIBIT"B" Scope of Services—FY 2018-19 Outside Agency Performance Agreement Agency Name: The Arc of the Triangle,Inc. Program Name: Community Programs and Individual Services Funding Award: $33,200 Outline how the agency will spend Orange County's funding award. Expense Description Amount Staff Salary $22,000 Rent $3,000 Mileage $200 Marketing and advertising expense $1000 Telephone/Internet $2000 Materials and Supplies for programs $3000 Insurance(Liability,Workers Comp,Cyber,Abuse and Molestation) $2000 TOTAL$33,200 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2019. • Expand Community programs to Orange County citizens with disabilities not familiar with The Arc. • Funding for these programs will go directly to coordinate and monitor activities that enable people with UDD to become engaged with the community through the use of community volunteers, spaces and resources. This is consistent with the Chapel Hill, Carrboro and Orange County town goals of Creating a Place for Everyone and Nurturing Our Community. • Meet multiple needs that are priorities for Chapel Hill, Carrboro, and Orange County. Provide educational and family resources for our participants through Cooking, Arc Hoops and TSAN. Teach civic engagement, by working together to create flower arrangements or food creations that are donated to other local nonprofit or governmental agencies. • People with UDD seen in the community as capable and contributing members of society. This forms positive impressions and mutually beneficial relationships with the community. By educating the business community when there is a job opening or a volunteer opportunity these opportunities are equally extended to someone with a disability as would be their typical peer. Build stronger communities,fosters equality, and diminishes bullying and prejudices. DOCUSIgned by: �F Executive Director 11/20/2018 4ss Certified by: Es7osEcoaon�8 ... Title: Date: (Provider's Signature) DocuSign Envelope ID:9F46lF1C-C86C-42DC-B78C-50FC18D204DF 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 Encourage inclusive and integrated programming with non-disabled peers(currently less than 5% 10% of our participants are adults without disabilities)(60 participants with disabilities served now- increase we would like that ratio to improve so 90%are people with disabilities and a minimum of 10% are their typicalpeers) Total participation in Petals with a Purpose&HOPE Gardens for FY 18-19 25 Total participation in Triangle Self-Advocacy Network for FY 18-19 15 Total participation in Cooking&Nutrition Class;Arc HOOPS;Friday Fun Day for FY 18-19 60 Total participation in Community Connections for FY 18-19 25 DOCUSigned by: � U Executive Director 11/20/2018 Certified by: s7osEcoaoa,sas,.. Title: Date: (Provider's Signature) DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF ATTACHMENT "A" Orange County Certifications—FY 2018-19 Outside Agency Performance Agreement Chief Contact,Administrators,Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name,title,residential address;phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing,with the name, physical address,mailing address and if possible,phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not,please explain on a separate sheet of paper. Alignment with Organization's Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. Certified by: OocuSigned by: Title: �Ig� P[aU' a ( Executive Director Date: 11/20/2018 s7osEcoaon3sass.. (Provider's Signature) (The Arc of the Triangle) Orange County Outside Agency Performance Agreement Page 12 of 9 Rev. 8118 DocuSign Envelope ID:9F461F1C-C86C-42DC-B78C-50FC18D204DF DATE(MMIDD/YYYY) � CERTIFICATE OF LIABILITY INSURANCE 76/28/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Kendra A.Biddle,CPCU,CIC Marsh &McLennan Agency LLC PHONE FAX 440 South Church St., Ste 500 (A/C. A/C No Ext: 336-899-2410 A/c No):212-607-6554 Charlotte NC 28202 ADDRESS: Kendra.Biddle@marshmma.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance Company of America 12572 INSURED ARCOF-4 INSURER B: Key Risk Insurance Company 10885 The Arc of the Triangle 1709 Legion Rd, Suite 100 INSURER C: Chapel Hill NC 27514 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:543078626 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICYNUMBER MM/DD/YYYY MM/DDIYYYY A X COMMERCIAL GENERAL LIABILITY S2258874 7/1/2018 7/1/2019 EACH OCCURRENCE $1,000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 MED EXP(Any one person) $20,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY❑ PRO- JECT LOC PRODUCTS-COMP/OP AGG $3,000,000 OTHER: $ A AUTOMOBILE LIABILITY S2258874 7/1/2018 7/1/2019 COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident E $ A UMBRELLALIAB X OCCUR S2258874 7/1/2018 7/1/2019 EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION KEY0137206 7/4/2018 7/4/2019 X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 A Professional S2258874 7/1/2018 7/1/2019 Incident 1,000,000 Liability Aggregate 3,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Above coverage also includes Abuse or Molestation Liability: $1,000,000 Each Abuse or Molestation Limit $3,000,000 Aggregate Limit CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Orange County Government ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Human Services P O Box 8181 AUTHORIZED REPRESENTATIVE 200 S Cameron St Hillsborough NC 27278 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD