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HomeMy WebLinkAbout2019-483-E DSS - OCIM performance agreement DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT,made and entered into the first day of July 2019, ("Effective Date")by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and Orange Congregations in Mission, a not-for-profit corporation,located at 300 Millstone Drive,Hillsborough,NC 27278 ("Provider"). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need,as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth,the County and Provider agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1,2019 to June 30,2020. 2. Scope of Services. a. Provider will provide services to the residents of Orange County, as outlined in the Outside Agency Funding Application and any amendments or revision thereto (Exhibit "A") and Emergency Assistance Scope of Work ("Exhibit B"), both of which are attached and hereby incorporated into this document as if set out herein. The Scope of Services in Exhibit A and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit C. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate funds for the provision of services described in Exhibit A, Scope of Services, and more particularly described in the Program Budget or Revised Program Budget, the maximum sum of Seventy-Eight Thousand, Four Hundred and Fifty Dollars ($78,450). The County also agrees to appropriate funds for the provision of services described in Exhibit B, the maximum sum of Fifty One Thousand Dollars ($51,000). The total amounted appropriated by the County to Provider for these services shall be One Hundred Twenty Nine Thousand,Four Hundred and Fifty Dollars($129,450). b. All funds appropriated shall be used for purposes described in Exhibit A and Exhibit B. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services provided in Exhibits A and B, at the discretion of the County the Provider may be required to repay the funds to the County. c. Funds Appropriated for Outside Agency Funding(Exhibit A) Services. Orange Congregations in Mission Orange County Outside,Agency Performance,4greemenc Revised 612018 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 i. For funds appropriated for Exhibit A services, the Provider shall be paid in four equal installments in the amount of $19,612,50. The first payment is contingent upon receipt of the agency's performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. ii. The County's obligation to matte the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. iii. Once Provider has satisfied its obligations as provided in c.l. above payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. d. Funds Appropriated for Emergency Assistance(Exhibit B) Services. i. For fiends appropriated for Exhibit B services, the County will reimburse Provider for services described in Exhibit B up to the limits allocated by this Agreement. The County will make an initial payment of $12,750 to Provider. The initial payment shall be used by Provider to pay for services as follows: $ 3,750 will be used to pay for staff costs and $9,000 will be used for reimbursement of client costs. Provider must provide documentation as provided in subsection ii below. Once Provider has provided documentation indicating that the initial payment has been expended then Provider shall submit documentation to County to be reimbursed for actual expenditures for all other approved services. ii. For reimbursement, Provider must submit copies of bills, checks, receipts and/or other proof of expenditures to the person designated by the County. Reimbursement will be provided bimonthly. iii. For reimbursement of staff costs, Provider shall submit the payment records for staff cost. The County will reimburse the Provider monthly upon receipt of a complete and correctly filed report. e. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance 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 17,April 17,and July 17 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 2 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 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. 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; 3 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 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 MDMVIUM 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. 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 4 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 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$ 14.95 per hour. To the extent possible, Orange County recommends that Provider provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered,to the last 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: County: Provider, Nancy Coston Executive Director Orange County Orange Congregations in Mission Department of Social Services 300 Millstone Drive Post Office Box 8181 Hillsborough,North Carolina 27278 Hillsborough,North Carolina 27278 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. 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. 5 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 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 Iimited 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.pbp). 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 bath parties as indicated by the dates set forth under signatures below. OocuSignr t, ed by: . Ski W66t, S. FM6,lAJ 7/23/2019 BE&2EMB'SA493 . Rev. Sharon S. Freeland,Executive Director Date n__ocu s _5igned--by:.._,-`7`?f Orange County Government I� V'cwuS lk�MA. 7/24/2019 A3ES1B12B364B4 . t30 nnie tiammersley, County Manager Date 5 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 Exhibit A Outside Agency Application and Scope of Services 8 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 COVER PAGE Applicant Contact Information Applicant Organization's Legal Name:Orange Congregations in Mission Applicant Organizations Physical Address:300 Millstone Dr. Hillsborough, NC 27278 Applicant Organization's Mailing Address:300 Miilstpne Dr. Hillsborough, NC 27278 Applicant Organization's Web Address:❑cimnc.org Executive Director: Rev.Sharon S. Freeland Telephone Number:519-732-6194 E-Mail:❑cimexecdirPernbargmaii.com Tax ID Number Funding Request Please list all Fiscal Year 2020 Human Services( IS)funding requested for all programs and the proposed use of funds(please list program name only) Program Carrboro- Chapel Drange Total HS 1iiH-HS Chun -HS Ex, YouthAftemchaalProgram $10,000 $15,000 $5,R00 $30,000 Samaritan Relief Ministry,food and financial assistance 58,415 Meals on Wheels food 34,000 Totals 92,415 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: r It 2-Z Executive Director Date Signature: Board Chairperson Date DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 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 rnembers of their immediate families,or their business associates. YES NO ❑ ® a} Employees of or closely related to employees of the Town of Carrboro,the lawn of Chapel Hall, 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. A full-time employee,who was facing a personal financial crisis, received financial assistance. The assistance was given after consultation with the Executive Director, 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 Gf 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: erutive Dire�c]torr Date Signature: Board Chairperson Date DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year): 0511981 2. Agency's Purpose/Mission (no more than a few sentences): To minister to the urgent needs of citizens of northern Orange County through the volunteer efforts of diverse congregations And individuals inspired by faith in God, and to enhance self-sufficiency and awareness of community resources. 3. Please provide a brief description of your organization's past achievements in carrying out similar projects and evidence of successful record of meeting proposed budgets and timetables(no more than 100 words). For the past 37 years, with the help of a supportive community and dedicated volunteers, OCIM has maintained a reputation of quick and compassionate responses to the human creeds in Orange County.As per Orange County quarterly reports, every effort is made to spend Orange County funds in the manner intended, in the time frame intended. Through new partnerships with Orange County's Family Success Alliance and Department of Social Services(Rent and Water bills)we routinely meet the goals and terms of record keeping and Budgetary requirements. 4. Living Wage: Does this agency pay permanent employees a minimum living wage?(Yes/No) yes If yes,is this agency an Orange County Living Wage Certified Employe ? No if no, please briefly explain. We have not submitted an application. Schedule of Positions: #of FTE—Full-Time Paid Positons: —7_ #of FTE—Part-Time Paid Positions:_4— PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 5. Program Name: Samaritan Relief Ministry Program Primary Contact and Title: Kay 5tagner Telephone Number: 919-732-6194 ex. 12 E-Mail: ocimsrm@embargmail.com 6. Please briefly describe the proposed program, including an explanation of how it aligns with the Town of Cha Pel Hill and Carrboro's Results Framework and Oran ge Cc u rty BOCC Goals and Priorities and the target population to benefit from the program. (100 words or less) The Samaritan Relief Ministry provides groceries and financial assistance for rent, utilities, and prescription medication for families and individuals living in northern Orange County; the geographical boundaries of the Orange County School District. This — .. ...................................-......... .......... Program information P a g e 7 o F 2 0 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 program aligns with Orange County's Goal Z: Ensure a community network of basic human services and infrastructure that maintains, protects,and promotes the well-being of all county residents. 7.Target Population: Please complete the table be law with numbers(not percentages)of individuals served and projected to be served. Program Target Population Demographics Projected Actual Estimated Projected 2018 2018 2019 2020 Gender Men 4,231 4,403 4,500 4,500 Women 5,610 5,292 5,400 5,400 Nonbinary/Genderqueer 8 10 10 Self-Describe Total 9,841 9,703 9,910 9,910 Race and Ethnicity HOUSEHOLDS Black or African-American 1329 1,305 1329 1329 American Indian a Alaska Native Asian White 1930 L 2,055 2,102 2102 Native Hawaiian or other Pacific Islander Other:specify 190 7 10 10 Total 3449 3,367 3,441 3441 185 Of the above,how many Hispanic/Latinx 180 185 185 Of the above,how many non-Hispanic/Latinx 3269 3,175 3256 3256 Total 3449 3,367 3441 3441 Age 0-5 years 1151 1,162 1,170 1,170 6-18 years 2617 2,408 2,450 2,450 19-50 years 5786 5,769 5890 5,890 51+years 287 364 400 400 Total 9841 9,703 9910 9910 Geographic Location Town of Chapel Hill Town of Carrboro Orange County{Outside of Chapel Hill/Carrboro) 9841 7,703 9910 9,910 Outside of Orange County Total 9841 9,703 9,910 9,910 Income Low-income(80%of the Area Median Income and Below) Please see 9,910 9,910 Income table In the attachments 9841 9,703 Total 9841 9,703 9,910 9,910 ............................... ....................................... ... .............. Program information P a g e 0 o ! �? �] DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 8. 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 2017-18 Estimated 2018-19 Projected 2019-20 Total Cost of Program $572,701 $629,208 $529,208 Total#of Individuals 9703 9910 9910 Cost Per Individual $59 $53.40 $53.40 9. Performance Indicators NEW THIS YEAR! For Chapel Hill and Carrboro applicants: Please complete the following chart with information about the Strategic Objective, Intermediate Result, and the Agency Performance Indicator for each program for which you are applying for funding. Please see the Results Framework in the Attachments section as a reference. Program Name: Strategic ❑ Children improve their educational outcomes Objective (please choose one from ❑ Residents Increase their livelihood security the Results Framework) ❑ Residents improve their health outcomes Intermediate Insert Intermediate Result here. Result (please choose one from the Results Framework) RESULTS Actual Estimated Projected 2017-18 2018-29 2019-20 Performance Insert Performance Indicator here. Indicators {Please choose al least one performance indicator to report on from the Results Framework,and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as —._..._............................................................_................. ......... _.........-_................................................. _ Progr-ern information P a g e 9 0 f 2 0 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 NEW THIS YEAR! For Orange County Applicants: WORK STATEMENT Performance Quantifiable FY 2017-18 Actual FY 2019-19 FY 2019-20 Projected Program Measurement Objective BOCC Goals and Priorities Outcome Estimated Outcome Outcome (Numerical) (Numerical) (Numerical) Track the number of ICD%of and times households 9,700 qualified receive food,via Individuals Access database, seeking help Produce man thiy with food well Samaritan report of total receive one 1 Rellef number of week offaad 9,700 Ministry Individuals receiving assistance a assistance,and maximum of Include the number eight times of Individuals Residents access the most within 12 receiving TFFAP appropriate social safety months food. net services 9679 9,700 100%and 120 qualified households requesting help Track the amount of will receive Samaritan financial assistance emergency 2 Relief individual financial to help Ministry households receive keep them In through Access their homes an database.Produce additional 30 monthly report of days or keep 247 300 300 total amount of Residents access the most utilities an an (117 with Orange (120 with Orange {120 with orange financiai assistance appropriate social safety additional 30 County Human County Human County Human given. net services days Services Funds] Services funds) Services funds} .............. -. _. ._................................................................... _.. . ._.. ... ......................................................... ..........................................................................._ Progrow li*ginatlon i :a 4,,.. .1 I r){ 1 u DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 AGENCY INFORMATION Please provide the following information about your agency: 1. date of Incorporation(Month/Year):0511981 2. Agency's Purpose/Mission(no more than a few sentences): To minister to the urgent needs of citizens of northern Orange County through the volunteer efforts of diverse congregations and individuals inspired by faith in God,and to enhance self-sufficiency and awareness of Community resources. 3. Please provide a brief description of your organization's past achievements in carrying out similar projects and evidence of successful record of meeting proposed budgets and timetables(no more than 100 words). For the post 37 years, with the help of a supportive community and dedicated volunteers, OC1M has maintained a reputation of quick and compassionate responses to the human needs in Orange County.As per Orange County quarterly reports,every effort is made to spend Orange County funds in the manner intended, in the time frame intended. Through new partnerships with Orange County's Family Success Alliance and Department of Social Services(Rent and Water bills)we routinely meet the goals and terms of record keeping and budgetary requirements. 4. Living Wage: Does this agency pay permanent employees a minimum living wage?(Yes/No) Yes If yes,is this agency an Orange County Living Wage Certified Employer? No If no,please briefly explain.We have not submitted an application Schedule of Positions: #of FTE—Full-Time Paid Positons: 7 #of FTE—Part-Time Paid Positions: 4 Program information Page 7 of 19 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 5. Program Name: Meals on Wheels Program Primary Contact and Title:Ka Ste+ ta_gner Telephone Number: 919-732-6194 ext. 12 E-Mail: ocimsrm@embargmail.com 6. Please briefly describe the proposed program, including an explanation of how it aligns with the Town of Chapel Hill and Carrboro's Results Framework, and Orange County SOCC Goals and Priorities and the target population to benefit from the program. (100 words or less) The Meals on Wheels program provides a home delivered meal to home-bound residents (primarily seniors) who live in northern Orange County and within a reasonable distance to an existing delivery route. This program aligns with Orange County's Goal 1: Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents. Not only do the most vulnerable members of our community get a nutritious meal five days a week, they also get a wellness check. if a driver expresses a concern, the MOW Coordinator makes appropriate contacts to ensure recipient safety. __.............................. ..........................._............._..........__..................................W......................._._ _..., — —- - ...-........... Program information Page 8 of 19 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 7.Target Population: Please complete the table below with numbers(not percentages)of individuals served and projected to be served. Program Target Population Demographics Projected Actual Estimated Projected 2017-18 2017-18 2018-19 2019-20 Gender Men 24 25 29 33 Women 79 61 fi6 72 N onbi na ry/G en derq ueer Self-Describe Total 103 86 95 105 Race and Ethnicity Black or African-American 68 26 29 34 American Indian or Alaska Native Asian White 65 60 66 71 Native Hawaiian or other Pacific Islander Other:specify Total 103 86 95 105 Of the above,how many Hispanic/Latinx 105 Of the above,how many non-Hispanic/Latinx 103 86 95 Total 103 86 95 105 Age 0-5 years 6-18 years 19-50 years 4 4 4 4 51+years 99 82 91 101 Total 103 86 95 105 Geographic Location Town of Chapel Hill Town of Carrboro Orange County(Outside of Chapel Hill/Carrboro) 103 95 105 Outside of Orange County 86 Total 103 86 95 105 Income Low-income(80%of the Area Medlan Income and Below) Please see 90 100 income table in the attachments 81 Total 98 81 g0 10S ....................... .................._...._...---............................ .__ ....... Program informadon P a g e 9 0 f 1 9 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 8. 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 2017-18 Estimated 2018-19 Projected 2019-20 Total Cost of Program $73,643 $67,665 $67,665 Total#of Individuals 86 95 95 Cost Per Individual $856.31 $712.26 $712.26 9. Performance indicators NEW THIS YEAR! For Chapel Hill and Carrboro applicants: Please complete the following chart with information about the Strategic Objective, Intermediate Result, and the Agency Performance Indicator for each program for which you are applying for funding. Please see the Results Framework in the Attachments section as a reference. Program Name: Strategic ❑ Children improve their educational outcomes Objective (please choose one from ❑ Residents Increase their livelihood security the Results Framework) ❑ Residents improve their health outcomes Intermediate Insert Intermediate Result here. Result (please choose one from the Results Framework) RESULTS Actual Estimated Projected 2017-18 2019-18 2019-20 Performance Insert Performance Indicator here. Indicators (Please choose at least one performance indicator to report on from the Results Framework,and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as needed,listing one per row ..._...............__..._............................................._.__...._.... - _.... -- ........ _..... _...... -._.. ._.... ._..... Program information Page 10 of 19 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 NEW THIS YEAR! For Orange County Applicants: WORT{STATEMENT Performance Quantifiable FY 2017-18 Actual FY Z018-19 FY 2019-20 Projected Program Measurement BOCC Goals and Priorities Objective Outcome Estimated Outcome Outcome (Numerical) (Numerical) (Numerical) 100%and 95 of program Participants that receive Will truck the Meals on food Assistance 1 Wheels number of meals will be able to 35 delivered each day. remain in their Residents access the most own homes as appropriate social safety long as safely net services possible. 85 95 2 3 _.........- .. . . ........_W. . program 14or1n;3Uni: Page l I ❑f 19 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 Agency Budget Operating Budget for Entire Agency AGENCY NAME: Orange Congregations in Mission Actual Percent AGENCY REVENUE 2018 Estimated 2019 Projected 2020 Change Private Donations $ 154,275 $ 96,324 $ 96,324 0% Agency Generated Revenue(fees,thrift shop, 1 $ 167,861 $ 201.500 $ 201.500 0% Local Government Grants: Human Services-Town of Carrboro $ - $ - $ - 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 90,571 $ 84,982 $ 84,982 0% Other-Orange County $ 43,459 $ 157,800 $ 157.800 0% Other-Town of Hillsborough $ 3,741 $ 6,000 $ 6.000 0% Other Government Grants Triangle United Way $ 5,102.00 $ 8,879.00 $ 8,879.00 $ - State Government $ - $ - $ - 0 Federal Government(CDBGIHOMEIetc.) $ - $ 28,677.00 $ 26,677.00 $ Private Foundation Grants $ 110,505.36 $ 105,150.00 $ 1Q5,150.00 $ revenue{Fundraising,non-cas $ 418,357 $ 370,000 $ 370,000 $ - Total Agency Revenue $ 993,872 $ 1,059,312 $ 1,059,312 0% AGENCY EXPENSES Compensation $ 412,563 $ 441,570 $ 441,570 0% Rent&Utilities (Occupancy) $ 130,761 $ 154,526 $ 154,526 00/0 Supplies& Equipment $ 3,339 $ 3,250 $ 3,250 0% Travel&Training $ 10,419 $ 10,117 $ 10,117 0% Other Expenses: program&non-cash food $ 502A78 $ 449,850 $ 449,850 0% Total Agency Expenses $ 1,059,56D $ 1,059,312 $ 1,059,313 % SURPLUSI(DEFICIT) FOR PERIOD: $ (65,688) $ (0] $ (1) -990D°Io FY 2018-19 Agency Budget DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 Program Budget Operating Budget for Program PROGRAM NAME Samaritan Relief Ministry Actual Estimated Projected Percent PROGRAM REVENUE 2018 2019 2020 Change Private Donations $ 20,816 $ 32,000 $ 32,000 0% Program Generated Revenue $ - $ - $ - 0 Local Government Grants: Human Services-Town of Carrboro $ - $ - $ - 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 43,090 $ 37,500 $ 37,500 0% Other-Orange County I $ - $ - $ - 0 Other-Town of Hillsborough $ 2,903 $ 6,000 $ 6,000 0% Other Government Grants Triangle United Way $ 2,664.00 $ 8,879.00 $ 8,879.00 $ State Government $ - $ - $ - 0 Federal Government(CDSGIHOMEIetc.) $ - $ 28,677,00 1 $ 28,677.00 $ Private Foundation Grants $ 31,475.00 $ 12,000,00 $ 12,000,00 $ revenue{fundraising, non-cas $ 410,455 $ 341,000 $ 341,000 $ Total Program Revenue 1 $ 511,403 $ 517,056 $ 466,056 -10% PROGRAM EXPENSES Compensation $ 77,159 $ 87,448 $ 87,448 0% Rent& Utilities(occupancy) $ 27,322 $ 24,990 $ 24,990 0% Supplies & Equipment $ 554 $ 800 $ 800 0% Travel&Training $ 233 $ 350 $ 350 0% Other Expenses: program &non-cash food $ 467,433 $ 415,520 $ 415,620 0% Total Program Expenses $ 572,701 $ 529,208 $ 529,208 0% SURPLUS/(DEFICIT) FOR PERIOD: 1 $ (61,298) $ (12,152) $ (63,152) -420% FY 2018-19 Program Budget DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 Program Budget Operating Budget for Program PROGRAM NAME Meals on Wheels Actual Estimated Projected Percent PROGRAM REVENUE 2018 2019 2020 Change Private Donations $ 3,520 $ 3.500 $ 3,500 0% Program Generated Revenue $ 4,775 $ 6,500 $ 6,500 0% Local Government Grants: Human Services-Town of Carrboro $ - $ - $ - 0 Other-Town of Carrboro $ - $ - $ - 0 Human Services-Town of Chapel Hill $ - $ - $ - 0 Other-Town of Chapel Hill $ - $ - $ - 0 Human Services-Orange County $ 47,482 $ 47,482 $ 47,482 0% Other-Orange County $ - $ - $ - 0 ❑ther-Town of Hillsborough $ - $ - $ - 0 Other Government Grants Triangle United Way $ 1,776.00 $ - $ - 0 State Government $ - $ - $ - 0 Federal Government(CDBGIHOMEIetc.) $ - $ - $ - 0 Private Foundation Grants $ 11,250.00 $ 3,150.00 $ 3,150.00 $ Other Revenue(fundraising) $ 4,439 $ 5,500 $ 5,500 $ Total Program Revenue $ 73,242 $ 66,132 $ 66,132 0% PROGRAM EXPENSES Compensation $ 19,323 $ 13,000 $ 13,000 0% Rent&Utilities Occupancy $ 18,322 $ 19,135 $ 19,135 0% Supplies&Equipment $ 481 $ 400 $ 400 0% Travel &Training $ 472 $ 1,000 $ 1,000 0% Other Expenses: Client food $ 35,045 $ 34,130 $ 34,130 0% Total Program Expenses $ 73,643 $ 67,665 $ 67,665 0%0 SURPLUS/(DEFICIT) FOR PERIOD: 1 $ (401) $ (1,533) $ (1,533) 0% FY 2018-19 Program Budget DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 Exhibit B Emergency Assistance Scope of Services Federal Tax Id.or SSN Contract# A. CONTRACTOR INFORMATION 1. Contractor Agency Name: Orange Congregations in Mission 2. If dierent from Contract Administrator Information in General Contract: Address Telephone Number: Fax Number: Email: 3. Name of Program{s}: Emergency Assistance 4. Status: { }Public (X)Private,Not for Profit { )Private, For Profit 5. Contractor's Financial Deporting Year July 1,2014 through June 30,2020 B. Explanation of Services to be provided and to whom: Through the Emergency Assistance Program, the Contractor will assist eligible individuals with rent and related costs as well as Town of Hillsboroujzh water bills and related costs.The County will reimburse the Contractor u to 3 000/month unless prior approval by County for a total of$36,000for the contract period for rent/related costs and/or Town of Hillsborou bills/related costs. To be eligible clients must: be residents of Orange Counjy,have income at or below 200%of the Federal Poverty Level,and have a household experiencing a financial crisis. Payments are limited to 200 within a 12-month period.The Coqujy will also reimburse the Contractor for staff costs (including salary FICA and fringe)for administering the Emergency Assistance Program up to$15,000 for the contract period.The Contractor will submit program paperwork provided by County_at time and dates designated by County. C. Funding reimbursement limits by category: Rent/related costs and Town of Hillsborough bills/related costs $36,000s 3 000per month} Staff costs: salary.FICA,fringe $15,000 D.Number of units to be provided:NA E. Details of Billing process and Time Frames:One fourth of the contract amount( 9 000 for rent and related costs and$3 750 for staff costs)for Emergency Assistance services described in this contract will be paid upon receipt of a completed contract.The Contractor will subsequentl)�provide Vayment records for actual costs for the initial payment.After payment records are Rrovided for the entire initial payment,the County will reimburse the Contractor for services described in this contract M to the budgetary limits of the contract allotment. The Counjy will reimburse the Contractor for actual ex enditures for approved services provided For reimbursement,the Contractor must submit copies of bills,checks,receipts and/or other proof of expenditures by the fifth of the month for the preceding month's expenditures to the designated County Administrator. The Contractor must submit a payment records for staff cost reimbursement. The County will reimburse the Contractor month/ u on receipt of a complete and correctly filed re art. 9 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 F.Area to be served/Delivery site(s): ..�range County DocuSigned by: DocuSigned by: 66sf ow . Sic w6v, 5- �AE1E196A83B455 . BE&2EC43D675A483 . Nancy Coston,Social Services Director (Signature of Contractor) 7/23/2019 7/23/2019 (Date Submitted) (Date Submitted) 10 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 EXIMIT"C" Scope of Services—FY 2019-20 Outside Agency Performance Agreement Agency Name: Orange Congregations in Mission, Inc. Program Name: Samaritan Relief Ministry Funding Award: $37,500 Outline how the agency will spend Orange County's funding award. Expense Description Amount Personnel-program manager salary 10,000 Rent and utility assistance 8,000 Food 19,500 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2019, ■ Provide a week's worth of groceries to referred households a maximum of eight times in twelve months. ■ Provide emergency financial assistance for rent and utilities. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County,only, (all Towns and municipalities), if you use percentages,you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Number of meals/grocery services provided to qualifying households 9,184 Number of qualifying households receiving emergency financial assistance for rent and utilities 175 GocuSigned by:Certified by:ErBE62EM67SA483 tAlk. ��t r6t& �- Fft a.kAj y Executive Director Date:7/23/2019 . (Provider's Sigi,Lurv) Orange County Outside Agency Performance Agreement Revised 5/2018 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1 F3178D3BE7 ExIMIT"C" Scope of Services—FY 2019-20 Outside Agency Performance Agreement Agency Name: Orange Congregations in Mission, Inc. Program Name: Meals on Wheels Funding Award: $40,950 Outline how the agency will spend Orange County's funding award. Expense Description Amount Meals on Wheels meal purchases $20,842.50 Personnel-salary and mileage to support programming $20,107.50 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2020. • Delivery of meals to elderly/disabled residents five days/week(Monday-Friday) ■ Increase meal delivery to Cedar Grove and Little River Townships as well as keeping up with referrals from other parts of northern Orange County. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Or� ange County,only(all Towns and municipalities). if you use percentages,you must also provide the total number of participants within that measure's description or for an earlier performance measure. Performance Measures Anticipated Results Number of meals delivered 10,237 Nwnnber of new direct interviews conducted and/or individuals enrolled in program 20 OacuSignred by: . S�iGU'66t, S, VC.tpt 7/23/2019 Certified b Executive Director Date: y' 6E62EC6�675A483 . (Provider's Signature) 2 DocuSign Envelope ID: 1056F994-88AA-4336-8102-E1F3178D3BE7 OP ID: LP CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDIYYYY) ik� 1 01/17/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements). PRODUCER CONTACT NAME: Jeff Rubish High&Rubish Insurance Agency PHONE F P.O.Box 3040 M. 919-913-1144 AIC Nn:819-913-1155 6015 Farrington Rd.Ste 101 E-MAIL Chapel Hin,7IC 27517 PRooucERnatalie h1 handru6ish.Com Jeffrey A.Rubish CUSTOMERo •OCIM--1 INSURE S AFFORDING COVERAGE NAIC 4 INSURED Orange Congregations In INSURER A:Cincinnati Insurance Company 10677 Missions, Inc. 1NSURER R;Hartford Underwriters Ins. 30104 300 Millstone Drive Hillsborough.NC 27278 INSURERC: INSURER 0 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. iNSR D POLICY EFF POLICY EXP UMI75 LTR TYPE OF INSURANCE POLICY NUMBER MMIOD MMID IDN-M) GENERAL LIABILITY EACH OCCURRENCE 3 2,000,0001 A X COMMERCIAL GENERAL LIABILITY X ECP0349072 10116/2018 10/1512021 PREMISES Ea occurrence $ 2,000,00 CLAIMS-MADE ❑X OCCUR MEO EXP(Any one person) $ 10,00 PERSONAL&ADV INJURY $ 2,000,00 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP1oPAGG $ 4,000,00 X POLICY PRO- LOC 4 AUTOMOBILE LIABILITY COM SINED 8 1 NGLE LIMIT S 2,000,00 (Ea acddanq ANY AUTO BODILY INJURY(Per person) 5 ALL OWNED AUTOS BODILY INJURY(Per acdcant) 4 SCHEDULED AUTOS PROPERTY DAMAGE A x HIRED AUTOS F�A0349072 101151201 S 1011 SM021 (PER ACCIDENT) $ X NON-OWNED AUTOS $ a UMBRELLA LIAR OCCUR EACH OCCURRENCE 5 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE 5 RETENTION $ S WORKERS COMPENSATION! x WC STATIJ- OTH• AND EMPLOYERS'LIABILITY B ANY PROPRIETORIPARTNER/Fxr=CtMVE Y N/A 2WECBV6360 08f1812018 08118/2019 E.L.EACH ACCIDENT 4 100,00 OFFICERIMEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYE 4 100,00 If Ee nder Ci ORIPTiON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 A Sexual Misconduct JECP0349072 10/1512018 10/1512021 Occurence 1,000,000 Aggregate 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES fAttach ACORD 101,Additional Remarks Schedule,II more space is required) Additional Insured Status Applies to Holder CERTIFICATE HOLDER CANCELLATION ORANG•1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE ORANGE COUNTY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. P 0 Box 8181 302 W.Tryon 5t. AUTHORIZED REPRESENTATIVE Hillsborough,NC 27278 Q 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD