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2021-098-E Social Svc-Chapel Hlil Outreach Project outside agency agreement
DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 OUTSIDE AGENCY AND CARDINAL MANAGED CARE FUNDS PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2020, ("Effective Date") by and between the County of Orange, a political subdivision of the State of North Carolina, Post Office Box 8181, Hillsborough,North Carolina,27218, ("County") and Chapel Hill Outreach Project,Inc. DBA KidSCope.,a not-for-profit corporation, located at 101 Cloister Court, Suite D, Chapel Hill, North Carolina 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<<Agencys_Name» agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2020 to June 30,2021. 2. Scope of Services. a. Provider will provide services to the residents of Orange County, as outlined in the attached Cardinal Managed Funds Work Statement and any amendments or revisions thereto which is attached as Exhibit A,which is 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 B, Scope of Services and may be more particularly described in the Revised Program Budget in Exhibit B, the maximum sum of $75,000.00 in Outside Agency Funds. ii. The Provider shall be paid Outside Agency Funds in four equal installments in the amount of$18,750.00.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. i. Cardinal Managed Care Funding. The County agrees to appropriate funds for the provision of services described in Exhibit A, Work Statement and may be more («Agencys Name») Orange County Outside Agency and Cardinal Managed Care Fund Performance Agreement Revised 112021 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 particularly described in the Revised Program Budget in Exhibit C,the maximum sum of$15,000.00 in Cardinal Managed Care Funds. ii. The Provider shall be paid Cardinal Managed Care Funds in twelve equal monthly installments in the amount of$1,250.00.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. 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 10, April 10, and July 10 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'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: 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 («Agencys Name») Orange County Outside Agency Performance Agreement Page 3 Rev. 112021 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 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. f. 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. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: .... (aMgencys Name») Orange County Outside Agency Performance Agreement Page 4 Rev. 112021 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 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 irijury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury,bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents,consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A- Statutory State NC & Coverage B -Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies(with the exception of Worker's Compensation and Professional Liability)required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough,NC 27278 d. Nothing in this section is intended to affect or abrogate the County's sovereign immunity defenses. 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. S. 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. (aAgencys Name») Orange County Outside Agency Performance Agreement Page 5 Rev. 112021 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 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 parry 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 fiends 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 $ 15 per hour. To the extent possible, Orange County recommends that Provider 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: County: Finance&Administrative Services Provider: Terry David Orange County Chapel Hill Outreach Project,Inc. Post Office Box 8181 DBA KidSCope Hillsborough,NC 27278 101 Cloister Court, Suite D Chapel Hill,NC (aAgencys_Nameh Orange County Outside Agency Performance Agreement Page 6 Rev. 112021 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 27514 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 I IA 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. bdan4.vn,behalf of the Provider 1/26/2021 Terry David, Chapel Hill Outreach Project,Inc. DBA KidSCopc Date mdaauJ QA,behalf of Orange County Government J 6V-'W't, (�c+�vxt VSIt�, 2/9/2021 Bonnie Hammersley, County Manager Date (aAgencys_Name») Orange County Outside Agency Performance Agreement Page 7 Rev. 112021 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 ORANGE COUNTY—DEPARTMENT USE ONLY Party/Vendor Name: Chapel Hill Outreach Project,Inc.DBA KidSCope Party/Vendor Contact Person: Term+David Contact Phone: 919-644-6590 Party/Vendor Address: 101 Cloister Court, Suite D City Chapel Hill State: NC Zip: 27514 Department: Social Services Amount: $90,000 Purpose: outside agency funds + Behavioral Health MOE Budget Code(s): 10420020-710050/10495050-710015 Vendor# 800060 (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No® Contract Type:(Check one)New❑ Renewal® Amendment ❑ Effective Date 7/1/2020 Approved by Board Yes®No❑ Agenda Date: 6/16/2020 This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: DocuSigned by: Department Director's Signature NOUAU1 (him, Date: 112712021 Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: Information Technologies (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer Date: Risk Management This agreement is approved for sufficienc ddb�»r gstandards,specifications, and requirements: Q�Sa / / Office of the Risk Management Officer 1,oV�tb Date: 1 26 2021 Financial Services This instrument has been pre-audited' R%m"oequired by the Local Government Budget and Fiscal Control Act: +� 2/1/2021 Office of the Chief Financial Officer Date: Legal Services This agreement is approved as t cffl%ffdaitl'd sufficiency: Office of the County Attorney Date:2/8/2021 Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board Date: ((Mgencys_Name») Orange County Outside Agency Performance Agreement Page 8 Rev. 112021 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 ATTACHMENT "A" Orange County Certifications—FY 2021 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. DocuSigned by: fi �ANU/� . 1/26/2021 Certified by: Executive Dir. � Title: Date: (Provider's Signature) («Agencys_Name») Orange County Outside Agency Performance Agreement Page 12 Rev. 112021 ti ► Q 1 DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 COVER.PAGE Applicant Contact Information Applicant Organization's Legal Name: Chapel Hill Training Outreach Project, Inc. Applicant Organization's Physical Address: 800 Eastowne Dr., Suite 105, Chapel Hill, NC 27514 Applicant Organization's Mailing Address: 800 Eastowne Dr., Suite 105, Chapel Hill, NC 27514 Applicant Organization's Web Address: www.CHTOP.orq Executive Director: Terry David Telephone Number: 919-490-5577 E-Mail: TDayid(a_)chtop.orq Tax ID Number: 58-204362 Funding Request Please list all Fiscal Year 2021 Human Services (HS) funding requested for all programs and the proposed use of funds (please list ro rain name only) Program Carrboro- Chapel Orange Total HS Hill - HS County-HS KidSCope Outreach Therapy $3,000 $5,000 $96,000 $104,000 Operations and Personnel KidSCope Outreach Consultation $50,000 $50,000 Operations and Personnel Totals $3,000 $55,000 $96,000 $154,000 Briefly explain your proposed use of Rinds: KidSCope proposes the use of funds to support staff and program expenses for the following services: • Customized assessment and evaluation for children ages birth to 5, and their familieE to determine strengths and needs, • Social-emotional/behavioral health services using researched, evidence-based treatment and consultation modalities providing both home visiting, school-based, an office-based options. These programs are designed to give children a healthy start in the early years when relationships and experiences influence brain development the most. • Parent education that encourages and supports positive family relationships and interactions, particularly in the early years. ___. .............__. ........ DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 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. s;z _� --" i - C: Executive Director Date ature; `- Board Chairzerson Date ...... .............. . .._. ................_......... .................._.. ......................_........_._. ............................................... ......................................_......................................... . ....._....... .......................................... Coder Page P a g e 7 o f 2 8 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 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 ar members of their immediate families,or their business associates, YES NO ❑ xn a)Employees of or closely related to employees of the Town of Carrboro,the Town of Chapel Hill, or Orange County? ❑ x❑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? ❑ x❑c)Current beneficiaries of the program for which funds are being requested? ❑ x❑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: t7 tive,,Direct r __.�.. �. Date y SI ature: oar C person Date .._......._......................_......_....................._.....................................,........_...........................................................,........_.......................................................................... ........_.._...........,................._.............................................,............................................................._.._......._......._... Cover Page Page 8 of 28 DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year): 04/1988 2. Agency's Purpose/Mission (no more than a few sentences): The mission of KidSCope is to provide comprehensive early childhood developmental/mental health support to young children, their families, and care providers. Through the use of research and specialized evidence-based services, KidSCope aims to give children a healthy start in the early years, when relationships and experiences influence future life success the most. 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). KidSCope recognizes the importance of fiscal stewardship and the need to meet funders' success metrics. Throughout the past ten fiscal years, KidSCope has received funding for and provided crucial outreach/mental health therapy services to an average of 90 children and their families throughout Orange County annually. KidSCope therapists facilitated caregivers' learning about trauma's effects on children and provided effective strategies for addressing them. KidSCope has been successful in consistently meeting proposed budgets and timelines for multiple funding sources. By assuring that KidSCope services for families would continue and thrive using a variety of innovative modalities, supports for families have endured. 4. Living Wage: Does this agency pay permanent employees a minimum living wage? (Yes/ No) N o If yes,is this agency an Orange County Liviniz Wale Certified Employer? No If no,please briefly explain. Paying our employees a "living wage" is a goal for the KidSCope program that we are close to achieving. KidSCope is, however, a program of the Chapel Hill Training Outreach Project, Inc., a non-profit with many employees. Although the goal of paying a minimum living wage is an admirable one, KidSCope is not involved in salary decisions for the entire agency. Schedule of Positions: # of FTE — Full-Time Paid Positons: _28_ # of FTE — Part- Time Paid Positions: 12 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. Sa. Program Name: KidSCope Outreach: Early Childhood Mental Health Therapy Program Primary Contact and Title: Lara Kehle, Director DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 Telephone Number:919-644-6590 E-Mail: LKehle(a)kid scope.chtop.org 5. 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 BOCC Goals and Priorities, and the target population to benefit from the program. (100 words or less) KidSCope's Outreach/Therapy provides supports and interventions with young children and their families to address significant mental health problems. Young children respond to and process emotional experiences and traumatic events in ways that are very different from adults and older children. This aligns with OCBOCC Goal #1 to ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents by offering specialized services for our youngest residents. This aligns with CHC SR1 Children birth-to-K improve their education outcomes, and IR1.1 access early childhood development opportunities including therapy, interventions and support services. 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 Projected Projected 2018-19 2018-19 2019-20 2020-21 Gender Men 60 50 60 65 Women 35 38 50 55 Non binary/Genderqueer Self-Describe Total 95 88 110 120 Race and Ethnicity Black or African-American 15 18 20 25 American Indian or Alaska Native 0 0 0 0 Asian 3 0 6 6 White 33 25 36 36 Native Hawaiian or other Pacific Islander 0 0 0 0 Two or more races Some other race 44 45 1 48 53 Total 95 88 110 120 Of the above, how many Hispanic/Latino 45 36 40 45 Of the above, how many non-Hispanic/Latino 50 52 70 75 Total 95 88 110 120 .Age 0-5 years 93 83 108 115 Page 10 of 28 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 6-18 years 2 5 2 5 19-50 years 51+years Total 95 88 110 120 Geographic Location Town of Chapel Hill 25 27 30 35 Town of Carrboro 21 15 26 26 Orange County(Outside of Chapel Hill/Carrboro) 45 39 50 55 Outside of Orange County 4 7 4 4 Total 95 88 110 120 Income *Low-income(80%of the Area Median Income and Below) Please 89 95 see income table in the attachments 75 69 Total 1 95 88 110 120 *Low income determined by#of children who are Medicaid eligible 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 2018-19 Projected 2019-20 Projected 2020-21 Total Cost of Program 146,638 178,729 186,436 *Total #of Individuals 202 260 285 Cost Per Individual $726 $687 $654 *Includes children and family members served 9. Performance Indicators 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: KidSCope Outreach Strategic X Children improve their educational outcomes Objective ❑ Residents Increase their livelihood security (please choose one from the Results Framework) ❑ Residents improve their health outcomes Intermediate Insert Intermediate Result here. Result (please chooseonefrom 1.1 Children birth-to-K access early childhood development opportunities. the Results Framework) Fro rain information Page 11 of 28 DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 RESUtTSy gklllr al Projected Projected MANARTIF 2018=19 .t '°-2019-20 2020-21 Performance Insert Peiformance Indicator 88 children 110 children 120 children Indicators here. were are are (Please choose at least referred for estimated to estimated to oneperformance % and #of children referred to services out be referred be referred indicator to report on socio-emotional health of the 95 for services, for services, from the Results Framework,and add services that complete an age estimated, of which 88, of which 98, additional performance appropriate therapeutic or out of which or 80%, will or 82%, will indicators thatyou 80 children complete an complete an would like to report to enrichment program o the Towns. Please or 84 /o age age insert additional rows as completed appropriate appropriate needed,listing one per an age therapeutic therapeutic row). appropriate or or therapeutic enrichment enrichment or program program enrichment program DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 I TY Outside Agencies/Human Services Please use the drop down menu below to select which function area best aligns with your agency and program(s) in which you are requesting funding. Please select only one from the drop down menu below. Behavior Health If you selected other,please tell us what function area best aligns with your organization: Please indicate three program goals/performance measures below. A few notes: • If you use percentages, please put the actual number equivalence. • Please ensure your performance measures are outcome based and not outputs. Provide evidence-based therapeutic interventions Program Goal# 1 to improve the mental health and wellness of children and families identified through outreach activities Performance Measure #of individuals (families and providers) reached (How will you accomplish your goal?) through outreach activities in the community Actual Results n/a (Outcome) Ending F718-19 Projected Results 30 individuals reached (Outcome) Ending FY2020 Projected Results 50 individuals reached (Outcome) Ending FY2021 Provide and complete evidence-based therapeutic" Program Goal#2 interventions to improve the mental health and wellness of children and families Performance Measure #and% of children (and families) completing (How willyou accomplish your goal?) , M therapeutic interventions Actual Results 80, or 84%, of the 88 children referred (Outcome) y Ending FY18-19 ,x . Projected Results 88, or$0%, of the'110 estimated children' (Outcome) y Ending FY2020 ri ?' S41, Projected Results 98,,or 82%, of the 120 estimated children (Outcome) aa � x 3 Ending FY2021 t Program infortnation P a g e 13 o f 2 8 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 Outside Agencies/Human Services Provide evidence-based therapeutic interventions Program Goal#3 to improve the mental health and wellness of children and families in order to increase family protective factors Performance Measure #and % family members of referred children (Howwillyouaccomplish your goal?) provided counseling/education Actual Results 119, or 98%, of the 122 family members (Outcome) Ending FY18-19 Projected Results 108, or 90% of the estimated 120 family members (Outcome) Etiditkq FY2020 Projected Results 126, or 90%, of the estimated 140 family members (Outcome) Endhig FY2021 Program information Page 14 of 2 DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 5b. Program Name: KidSCope Outreach: Early Childhood Mental Health Consultation (Town of Chapel Hill only for 2020-2021) Program Primary Contact and Title: Lara Kehle, Director Telephone Number:919-644-6590 E-Mail: LKehle(@kidscope.chtop.orq 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 BOCC Goals and Priorities, and the target population to benefit from the program. (100 words or less) KidSCope's Outreach/Consultation provides supports and interventions to young children, their families, providers and classmates to address classroom challenges in alignment with CHC SR1 Children birth-to-K improve education outcomes, and IR1.1 access early childhood development opportunities including in-school interventions/supports. Research says, "Most potential mental health problems will not become mental health problems if we respond to them early."* There was a gap in our community for the past four years for a specialized program supporting childcare providers and families of children 0-5. Through Consultation, Providers gain skills to better meet social-emotional needs, fostering growth for all children in their care. * https://developingchild.harvard.edu/resources/inbrief-early-childhood-mental- health-2/ 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 Projected Projected 2018-19 2018-19 2019-20 2020-21 Gender Men 15 Women 10 N o n b i n a ry/G e n d e rq u e e r Self-Describe Total n/a n/a n/a 25 Race and Ethnicity ' Black or African-American 8 American Indian or Alaska Native 0 Asian 4 White 8 Native Hawaiian or other Pacific Islander 0 Two or more races Some other race 5 Total n/a n/a n/a 25 r' a A 5 C} t 2 8 DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 Of the above, how many Hispanic/Latino 10 Of the above, how many non-Hispanic/Latino 15 Total n/a n/a n/a 25 Age 0-5 years 25 6-18 years 19-50 years 51+years Total n/a n/a n/a 25 Geographic Location Town of Chapel Hill 25 Town of Carrboro Orange County(Outside of Chapel Hill/Carrboro) Outside of Orange County Total n/a n/a n/a 25 Income *Low-income(80%of the Area Median Income and Below) Please 15 see income table in the attachments Total n/a n/a n/a 25 *Low income determined by#of children who are Medicaid eligible 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 2018-19 Projected 2019-20 Projected 2020-21 Total Cost of Program n/a n/a $50,000 *Total #of Individuals 300 Cost Per Individual $167 *Includes estimated children,family members,providers and classmates served 9. Performance Indicators 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: KidSCope Outreach Strategic X Children improve their educational outcomes Objective ❑ Residents Increase their livelihood security (please choose one front the ResultsFratne)vork) 171 Residents improve their health outcomes DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 Intermediate Insert Intermediate Result here. Result (please choose one from 1.1 Children birth-to-K access early childhood development opportunities. the Results Framework) RESULTS '- � Actual ProjeCfea Projected 2018-19 2019-20 2020-21 Performance Insert Performance Indicator n/a n/a 25 children Indicators here. are (Please choose at least estimated to oneperformance % and #of children referred to be referred indicator to report on socio-emotional health for services, from the Results Framework,and add services that complete an age Of which 21, additionalperformance or 84%, Will appropriate therapeutic or indicators thatyou complete an would like to report to enrichment program the Towns. Please age insert additional rows as appropriate needed,listing one per therapeutic row). or enrichment program Procrair,Mfori*nat€can i ; s e 1 7 o f 2 8 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 ��77 �O U A N •-• d H Z a C z w a a o m N 3 3 r m m O r m a a a s t- w m a w 3 o a t O m '^ p1 3 n < < v 0 H d O CA O N N X 0 rt S A d �.w O N A n O In O\ o N + m p V] ❑ u� .O 3 m rt a a O O N m 7 n m ON n 0 O a' O. z. n w a. m aao < 0 > m N ? -0 a a S. o O N m o ao f0 m 0 m O a n � m S _,w m 3 �• 0 p i1 m C, _ o ^ [o y 0 0 n < a a m a m T n a o 0 7 a Co- o . rt a zm sao 0 0 m 3 m < m y G� o m 0 _ ��33 ° m o � a r c o 3 c C a m am n m o� c m o n (] �' N n 3 p vi 7 y� C 7 •G O .t �n n ° _t S p� .J O . 0 o s a n o o n ;: a a a s a' o o _C) m a a oni a o °' o a oi s 0 3 �, 3 o' a m = o o m 3 :. co p No m as o n v n a 0 m °- s 3 ? k ` G m d ? m � o o, w m 3 N m 3 0 0° m - Q op xeq CL art m n m 3 n n n n m T n n -an m � n n . �o w 3 s o s T s 3 3 3 o s s a o 3 0 0 S p n 0 0 3 a a o n o 0 3 a a m n o 0 3 a n T a• m = = N n n m •ot o- m n 7 m = T N n w o a m N a m �, a io b b7 w o °1 O m as o p1 Q m oao m a O A CD o o co N v m o 3 m 0 d 0 m s T ?: a < v o o o < c 0 3 rto o a o o m o o a a M a m S a°qo H n d m y vi J c c o ° < o ° o < o ° g ^ o o w o' c 0 o O o n 3 T m O m a C C] n 3 7 c < a• NO a n 3 i ° a m ° O c CL MN I < o d m c W d �' rt 0-mC• m nni n. N C S N• j O O O• t:t �^ m o O. 7 m n io °—' °. 3 m •0 v u,. o f ,.� _^ cOi w = o- m x d v n o g O a n 0 m .F a c a n s 3 o v+ =_ m m o ° m a T o v a4 a a o a ua, D p1. v "o a a = tTl p� m a rn c a n m o m ti o a 3 c < v moo n Cr a `�to 3 a coo io w o te a,. m 3: 3 w m m m m o v m 3 a N O � 3:n o 3 0 - c7. n 3 3 < o o m n m ^ o n s m m m �' ° 3 < F3. 6 fD o 3 n° 3 0 ^ F` 0 0 5 a m N d' n . u m J N D y m o " = L' m m a a m o rr .* o om °o -g. � o <.. ? ° 3 7y a a a Q a m a m a� m rSo o.ao a o `< co o _ o o o m CL nao' < am $ m " C� ,off 3 3 m o b w < m o0 0. s m 0 z a -I o' 0 < 3 < !^ = a. m an, m rho a 0 y Elm CD Om m a j � m a o y a Rc � 3 v ° m o cyD N m m O n ID N O Q Q`G a m n �- m O a n >- O O' � n, S d.V a m C C y N n. rt a a 0 7 a O S '•G y y O CA rtrD S m 1 °O 7 0 rt ° a m N 0R ICif a j m \ O m U Q m rt � eo rn N S N.n.. S 3 no N n�i eat m .Oy, n ry S.� cL _ — O< O ° W'< rm+•v O'N m C G m Q m U Cmi S C S S M g C 3 = N 7 'O p m j C m 0 7 a m rt m O :3j m Ol 3 a 7 k a n m - r 3 r w m F m a a < ° V] S rt m n w a s 'O "O W a 3 s n A 7 r+ w (n Q co a m n 7- o m 0 a o O m a a o s o 0 c v O a N 7 a ,� m N m rt a f - n a N C� N ID c a N 7 0 m �n N n o m � 7 IL wN N 3 W y - m a N a CD 00 a CD m , a O c0 ° rt d S^ n OQ O n O m m m - m — � F+ O rt ° ' < � a � aw � m m N n m f0 n a yi - m a m _s d m n aso ro S - 3 ' m o m m o o m o m o 3 0 < z m m 5.' s o <° m, m m '. m n m m a m 3 o S �. m o o - v 0 3 m ° <°o °a 0 3 n m n s 0 < m v * o o n ° o c ° N 0 v 0 ° ° v s o,, a o 3 m c OR n m 3 n ° ° 3 a 3 o m `� S , 3 3 m a y N S a-' S. n .°r r_So. 7 u�, •9s 3 �^ h o y 3 N c�°.X c� _ a -a �rt n o o o f - a n o s °- m d 0 a 0 m o 0 3 a o m "w _ o n a o4 a� F. `<. n - < c ca m N in• �n Q a m 7 n = ['i.G = 3 O 3 Cn 3 rt 3 a C m d n m a NCr a a -O a) O O m m m oo S a m m n 3 d 3 ?y, cOq rt T m O m a e�-•in m Frogram information P a g e 2 0 of 2 DocuSign Envelope ID: D90F57Fl-8076-4358-9941-F62552053F84 . 0 d Gl 47 = p y W} 3�D m 0 a UF O CD CD 7 O CDN n n0 G O -0 0. N O n vCt O0 D O 3 n S OCD D 0 x O0 a ain I CO m c c o 3 H a � wC �f N O O a\ (p S D S O N 61 n DI -. d -• - .t S 7 _ D- 3 X C in D) Nw N D N ' n f V D D ti a O 3 O. OID N H D rt y O w D n 3 O o O M N D � � N S D 0 D M 3 3 D c S D q n a C �. < �. 2 < D- - n a c m aaa. o a n K 0 (D fD p O< O n D Dnj fD O O O N O N O DI O. DI D! fD D O M = n D1 .n C) rDi 7 D.. •° O O- O O (D C n O ID („+' < _ < M a s ? o m o o m C rF C a N N S O O_ O, F o3,. 3 0 D O D = N C N � Progrartl information Page 141 o c 2 8 DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 Agency Budget Operating Budget for Entire Agency AGENCY NAME: Chapel Hill Training-Outreach Project, Inc. (KidSCope) Actual Estimated Projected Percent AGENCY REVENUE 2018-19 2019-20 2020-21 Change Private Donations $ 19,029 $ 18,000 $ 18,000 0% Agency Generated Revenue (fees) $ 715,206 $ 712,533 $ 712,533 0% Local Government Grants: Orange County $ 75,000 $ 75,000 $ 96,000 28% Town of Chapel Hill $ 5,000 $ 5,000 $ 51000 0% Town of Chapel Hill-Community Impact $ - $ - $ 50,000 0 Town of Carrboro $ 2,500 $ 2,500 $ 3,000 20% Other Local: Strowd Roses 0 Other Local: NC Partnership for Children $ 500 0 Other Local: Misc $ 337 $ 1,000 $ 1,000 0% If more than 3 sources, please Other Government Grants Triangle United Way $ 48,140 $ 4,229 $ 4,229 0% State Government 0 Federal Govemment $ 407,533 $ 426,928 $ 426,928 0% Other Grants: NC Pre-K $ 182,850 $ 216,000 $ 216,000 0% Other Grants: CACFP $ 57,764 $ 58,000 $ 58,000 0% Miscellaneous/Other Revenue $ 364,626 $ 356,649 1 $ 356,649 0% Please list 3 largest Miscellaneous sources 18-19: Total Agency Revenue 1,878,48 5 1,875,839 1,947,339 4% AGENCY EXPENSES Compensation $ 1,388,537 $ 1,388,840 $ 1,438,646 4% Rent&Utilities $ 107,165 $ 107,435 $ 103,685 -3% Supplies &Equipment $ 58,402 $ 64,749 $ 67,656 4% Travel &Training $ 35,473 $ 41,314 $ 51,550 25% Other Expenses: $ 284,899 $ 283,380 $ 281,888 -1% Please list 3 largest"Other Expenses"20-21: Indirect Cost to CHTOP, Inc $ 119,003.10 Contracted services $ 89,760.00 Bulding supplies/maintenance $ 35,000.00 Total Agency Expenses 1,874,476 1 1,885,718 1,943,425 3% SURPLUS/(DEFICIT) FOR PERIOD: $4,009 1 ($9,879)1 $3,914 1 140% The surplus/deficit showing is impacted by the two developmental day centers and different/mutiple funding sources dependant on the children being served, and is an estimate at this time. DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 Program Budget Operating Budget for Program AGENCY NAME: Chapel Hill Training-Outreach Project,Inc. (KidSCope) Actual Estimated Projected Percent PROGRAM REVENUE 2018-19 2019-20 2020-21 Change Private Donations $ 16,885 $ 15,500 $ 15,500 0% Program Generated Revenue (fees) $ 21,922 $ 21,000 $ 21,000 0% Local Government Grants: Orange County $ 75,000 $ 75,000 $ 96,000 28% Town of Chapel Hill $ 5,000 $ 5,000 $ 5,000 0% Town of Chapel Hill-Community Impact $ - $ - 0 Town of Carrboro $ 2,500 $ 2,500 $ 3,000 20% Other Local: $ - $ - $ - 0 Other Local: Misc $ - $ - 0 If more than 3 sources, please Other Government Grants Triangle United Way $ - $ - $ - 0 State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue 0 Please list 3 largest Miscellaneous sources: $ - Total Program Revenue 1 21 307 119,000 140,500 18% PROGRAM EXPENSES Compensation $ 88,449 $ 116,256 $ 127,465 10% Rent&Utilities $ 23,310 $ 21,000 $ 18,036 -14% Supplies &Equipment $ 2,784 $ 2,800 $ 2,828 1% Travel &Training $ 7,320 $ 10,200 $ 14,000 37% Other Expenses: $ 24,774 $ 28,473 $ 24,107 -15% Please list 3 largest"Other Expenses": Fy 20-21 Indirect cost to CHTOP, Inc. $ 11,472.00 Computer maintenance $ 5,000.00 Bad Debt expense $ 2,500.00 Total Program Expenses $ 146,638 $ 178,729 $ 186,436 4% SURPLUS!(DEFICIT) FOR PERIOD: 1 ($25,331) ($59,729) ($45,936) 23% The surplus/deficit showing is impacted by the two developmental day centers and different/mutiple funding sources dependant on the children being served, and is an estimate at this time.See Agency Budget Form for overall picture. DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 Program Budget Operating Budget for Program AGENCY NAME: Chapel Hill Training-Outreach Project, Inc. (KidSCope) Actual Estimated Projected Percent PROGRAM REVENUE 2018-19 2019-20 2020 21 Change Private Donations $ - $ - 0 Program Generated Revenue (fees) 0 Local Government Grants: Orange County 0 Town of Chapel Hill 0 Town of Chapel Hill-Community Impact $ 50,000 0 Town of Camboro 0 Other Local: 0 Other Local: Misc 0 If more than 3 sources, please Other Government Grants Triangle United Way 0 State Government 0 Federal Government 0 Other Grants: 0 Other Grants: 0 Miscellaneous/Other Revenue 0 Please list 3 largest Miscellaneous sources: Total Program Revenue 50,000 0 PROGRAM EXPENSES Compensation $ $ - $ 38,597 0 Rent&Utilities $ - $ $ 2,900 0 Supplies &Equipment $ $ $ 1,429 0 Travel &Training $ $ - $ 2,500 0 Other Expenses: $ $ - $ 4,574 0 Please list 3 largest"Other Expenses": Fy 20-21 Indirect cost to CHTOP, Inc. $ 3,474.00 Advertising $ 500.00 Computer maintenance $ 300.00 Total Program Expenses $ - $ - $ 50,000 0 SURPLUS/(DEFICIT) FOR PERIOD: $0 $0 $0 0 DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 EXHIBIT`B" Scope of Services—FY 2020-21 Outside Agency Performance Agreement Agency Name: KidSCope 0 Program Name: KidSCope - Outreach Funding Award: $75,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Salaries, FICA, and Fringe $75,000 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2021. • Provide outreach activities for evidence-based therapeutic interventions • Provide evidence-based therapeutic interventions (on protective factors) • Complete evidence-based therapeutic interventions with children/families 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 50 #of individuals (families and providers) reached through outreach activities in the community 98/120, # and % of children (and families) completing therapeutic interventions 82% 126/140, # and % of familiy members of referred children provided counseling/ 90% education Do Title:cuSigned by: Certified by: �t VV �AaMd Executive Dir. Date: 1/26/2021 � (Provi er's E ectronic Signature) "You will sign this document electronically with your performance agreement. DocuSign Envelope ID: D90F57F1-8076-4358-9941-F62552053F84 EXHIBIT"B" Scope of Services—FY 2020-21 Outside Agency Performance Agreement Agency Name: Chapel Hill Training Outreach Project(MOE Funds) 40 Program Name: KIdSCope - Outreach Funding Award: $15,000 Outline how the agency will spend Orange County's funding award. Expense Description Amount Salaries, FICA, and Fringe $15,000 Program Services Outline the critical services(activities)the agency will employ to attain the Anticipated Outcomes below,by June 30,2021. • Provide outreach activities for evidence-based therapeutic interventions • Provide evidence-based therapeutic interventions (on protective factors) Complete evidence-based therapeutic interventions with children/families 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 50 # of individuals (families and providers) reached through outreach activities in the community 98/120, # and % of children (and families) completing therapeutic interventions 82% 126/140, # and % of familiy members of referred children provided counseling/ 90% education DocuSigned by: Executive Dir. 1/26/2021 Certified by: � Title: Date: (Provider's Electronic Signature) "You will sign this document electronically with your performance agreement. 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PRODUCER CONTACT NAME; Beth Wilkerson McGriff Insurance Services ,C' Ext:919 281-4500 NC,N. 888 746-8761 Post Office Box 13941 ADDRlEss: NCCertificateTeam(a mcgriffinsurance.com Durham,NC 27709 INSURER(S)AFFORDING COVERAGE NAIC# 919 281-4500 INSURER A:Philadelphia Indemnity Insurance Co. 18058 INSURED INSURER B:Accident Fund Ins Co of America 10166 Chapel Hill Training Outreach Project INSURER C Inc INSURER D 800 Eastowne Dr,Ste 105 INSURER E Chapel Hill,NC 27514 INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD/YEYYY MM/OPOUCOIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY PHPK2094162 2/05/2020 02/05/2021 EACH OCCURRENCE $1 000000 CLAIMS-MADE �OCCUR PREMISESOEaoccurrDenca $1 OOO,OOO MED EXP(Any one person) s 20,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 PRO- POLICY❑JECT LOG PRODUCTS-COMPIOPAGG $3,000,000 OTHER: $ A AUTOMOBILE LIABILITY PHPK2094162 2/05/2020 02/05/2021 ECOMBINED ccideISINGLE LIMIT $1,000,000 IX ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS $HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY X AUTOS ONLY Per accident A X UMBRELLA LIAB X OCCUR PHUB710568 2/0512020 02/05/2021 EACH OCCURRENCE $1 OOO 000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1 000 000 DED I X RETENTION$10000 $ B WORKERS COMPENSATION WCV6096247 12/17/2019 12/17/2020 X PER ITI Eli AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y/N E.L.EACH ACCIDENT $500 000 OFFICER/MEMBER EXCLUDED? 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ACORD 25(2016103) 1 of 1 The ACORD name and logo are registered marks of ACORD #S26342463/M25156989 AB4