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HomeMy WebLinkAbout2021-521-E-Aging-Charles House-Outside Agencies Orange County Outside Agency Performance Agreement ARPA Funds Revised 9/2021 Page 1 of 13 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2021, (“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, 27278, ("County") and Charles House, a not-for-profit corporation, located at 7511 Sunrise Rd, , Chapel Hill NC , 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, 2021 to June 30, 2022. 2. Scope of Services. a. Provider will provide services, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit “A” and incorporated by reference, to the residents of Orange County. The Scope of Services and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit B. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set for th in the Scope of Services. 3. Funding. a. The County agrees to appropriate for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of $23,363. b. 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, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $5840.75. The first payment is contingent upon receipt of the agency’s performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. d. The County’s obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 Orange County Outside Agency Performance Agreement Page 2 of 13 Rev.9/21 e. Once Provider has satisfied its obligations as provided in (d) payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. f. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 – December 31; January 1 – March 31 and April 1 - June 30. Reports are due on January 10, April 10, and July 10 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. Termination for Cause. In the event of any of the circumstances set forth below (hereinafter referred to as “default”), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten (10) business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County’s remedies in law or in equity. 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 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 Orange County Outside Agency Performance Agreement Page 3 of 13 Rev.9/21 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. 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. Responsibilities of the County. Cooperation and Coordination. The County has designated (Janice Tyler) to act as the County's representative with respect to the Project who shall have the authority to render decisions within guidelines established by the County Manager or the County Board of Commissioners and who shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker’s Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury, bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. v. Sexual Misconduct. Sexual Abuse/Molestation Insurance is required when Provider works directly one-on-one with children, elderly or other at-risk populations. 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 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 Orange County Outside Agency Performance Agreement Page 4 of 13 Rev.9/21  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  Sexual Misconduct $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. For more information see the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements, (each document is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php.) 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. 8. General Provisions. 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 identified, 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. b. 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, which is incorporated herein by reference and can be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php. The County may enforce this provision by an 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. c. 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 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 Orange County Outside Agency Performance Agreement Page 5 of 13 Rev.9/21 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. d. 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 Orange County Living Wage Policy, which is incorporated herein by reference, can be viewed at: http://www.orangecountync.gov/departments/purchasing_division/contracts.php. The County’s living wage is $ 15.40 per hour. To the extent possible, Orange County recommends that Provider provide a living wage to its employees. e. 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. f. 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. g. 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. h. 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. i. 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. j. 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. k. Compliance With The Contract Work Hours And Safety Standard Act. (See 29 C.F.R. §5.5) i. Overtime requirements. No Provider or sub-Provider contracting for any part of the contract work which may require or involve the employment of laborers or mechanics shall require or permit any such laborer or mechanic in any workweek in which he or she is employed on such work to work in excess of forty hours in such workweek unless such laborer or mechanic DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 Orange County Outside Agency Performance Agreement Page 6 of 13 Rev.9/21 receives compensation at a rate not less than one and one-half times the basic rate of pay for all hours worked in excess of forty hours in such workweek. ii. Violation; liability for unpaid wages; liquidated damages. In the event of any violation of the clause set forth in paragraph (b)(1) of 29 C.F.R.§5.5 the Provider and any sub-Provider responsible therefor shall be liable for the unpaid wages. In addition, such Provider and sub-Provider shall be liable to the United States (in the case of work done under contract for the District of Columbia or a territory, to such District or to such territory), for liquidated damages. Such liquidated damages shall be computed with respect to each individual laborer or mechanic, including watchmen and guards, employed in violation of the clause set forth in paragraph (b)(1) of 29 C.F.R. §5.5, in the sum of $26 for each calendar day on which such individual was required or permitted to work in excess of the standard workweek of forty hours without payment of the overtime wages required by the clause set forth in paragraph (b)(1) of 29 C.F.R. §5.5. iii. Withholding for unpaid wages and liquidated damages. The (write in the name of the Federal agency or the loan or grant recipient) shall upon its own action or upon written request of an authorized representative of the Department of Labor withhold or cause to be withheld, from any moneys payable on account of work performed by the Provider or sub-Provider under any such contract or any other Federal contract with the same prime Provider, or any other federally- assisted contract subject to the Contract Work Hours and Safety Standards Act, which is held by the same prime Provider, such sums as may be determined to be necessary to satisfy any liabilities of such Provider or sub-Provider for unpaid wages and liquidated damages as provided in the clause set forth in paragraph (b)(2) of 29 C.F.R. §5.5. iv. Subcontracts. The Provider or sub-Provider shall insert in any subcontracts the clauses set forth in paragraph (b)(1) through (4) of 29 C.F.R. §5.5 and also a clause requiring the sub-Providers to include these clauses in any lower tier subcontracts. The prime Provider shall be responsible for compliance by any sub-Provider or lower tier sub-Provider with the clauses set forth in paragraphs (b)(1) through (4) of 29 C.F.R. §5.5. l. Byrd Anti-Lobbying Amendment, 31 U.S.C. § 1352 (as amended). Providers who apply or bid for an award of $100,000 or more shall file the required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, officer or employee of Congress, or an employee of a Member of Congress in connection with obtaining any Federal contract, grant, or any other award covered by 31 U.S.C. § 1352. Each tier shall also disclose any lobbying with non-Federal funds that takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the recipient who in turn will forward the certification(s) to the awarding agency. DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 Orange County Outside Agency Performance Agreement Page 7 of 13 Rev.9/21 m. Clean Air And Federal Water Pollution Control Act (Applicable only if the contract is more than $150,000) i. Clean Air Act. (a) The Provider agrees to comply with all applicable standards, orders, or regulation issue pursuant to the Federal Water Pollution Control Act, as amended, 33 U.S.C. 1251 et seq. (b) The Provider agrees to include these requirements in each subcontract exceeding $150,000 financed in whole or in part with Federal assistance provided by FEMA. ii. Federal Water Pollution Control Act. (a) The Provider agrees to comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act, as amended, 42 U.S.C. § 7401 et seq. (b) The Provider agrees to report each violation to the ( ) and understands and agrees that the ( ) will, in turn, report each violation as required to assure notification to the Federal Emergency Management Agency, and the appropriate Environmental Protection Agency Regional Office. (c) The Provider agrees to include these requirements in each subcontract exceeding $150,000 financed in whole or in part with Federal assistance provided by FEMA. n. Suspension And Debarment i. This Agreement is a covered transaction for purposes of 2 C.F.R. pt. 180 and 2 C.F.R. pt. 3000. As such, the Provider is required to verify that none of the Provider’s principals (defined at 2 C.F.R. § 180.995) or its affiliates (defined at 2 C.F.R. § 180.905) are excluded (defined at 2 C.F.R. § 180.940) or disqualified (defined at 2 C.F.R. § 180.935). ii. The Provider must comply with 2 C.F.R. pt. 180, subpart C and 2 C.F.R. pt. 3000, subpart C, and must include a requirement to comply with these regulations in any lower tier covered transaction it enters into. iii. This certification is a material representation of fact relied upon by Orange County. If it is later determined that the Provider did not comply with 2 C.F.R. pt. 180, subpart C and 2 C.F.R. pt. 3000, subpart C, in addition to remedies available to Orange County, the Federal Government may pursue available remedies, including but not limited to suspension and/or debarment. iv. The bidder or proposer agrees to comply with the requirements of 2 C.F.R. pt. 180, subpart C and 2 C.F.R. pt. 3000, subpart C while this offer is valid and throughout the period of any contract that may arise from this offer. The bidder DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 Orange County Outside Agency Performance Agreement Page 8 of 13 Rev.9/21 or proposer further agrees to include a provision requiring such compliance in its lower tier. o. Access to Records. The following access to records requirements apply to this contract: i. The Provider agrees to provide State of North Carolina, the County, the FEMA Administrator, the Comptroller General of the United States, or any of their authorized representative access to any books, documents, papers, and records of the Contractor, which are directly pertinent to this contract for the purposes of making audits, examinations, excerpts, and transcriptions. ii. The Provider agrees to permit any of the foregoing parties to reproduce by any means whatsoever or to copy excerpts and transcriptions as reasonably needed. iii. The Provider agrees to provide the FEMA Administrator or his authorized representative access to construction or other work sites pertaining to the work being completed under the contract. iv. In compliance with the Disaster Recovery Act of 2018, the County and Provider acknowledge and agree that no language in this contract is intended to prohibit audits or internal reviews by the FEMA Administrator or the Comptroller General of the United States. p. DHS Seal, Logo, and Flags. The Provider shall not use the DHS seal(s), logos, crests, or reproductions of flags or likenesses of DHS agency officials without specific FEMA pre-approval. q. Compliance with Federal Law, Regulations and Executive Orders. This is an acknowledgement that FEMA financial assistance will be used to fund all or a portion of the Agreement. The Provider will comply with all applicable Federal law, regulations, executive orders, FEMA policies, procedures, and directives.” r. No Obligation by Federal Government. The Federal Government is not a party to this Agreement and is not subject to any obligations or liabilities to the non- Federal entity, Provider, or any other party pertaining to any matter resulting from this Agreement. s. Program Fraud and False or Fraudulent Statements or Related Acts. The Provider acknowledges that 31 U.S.C. Chap. 38 (Administrative Remedies for False Claims and Statements) applies to the Provider’s actions pertaining to this Agreement. t. 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 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 Orange County Outside Agency Performance Agreement Page 9 of 13 Rev.9/21 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. u. Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the Provider and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. v. Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: Orange County Provider’s Name Charles House Attention: Janice Tyler Attention: Paul Kleever P.O. Box 8181 Address: 7511 Sunrise Rd, Hillsborough, NC 27278 Chapel Hill NC 27514 Email:jtyler@orangecountync.gov Email: paul@charleshouse.org w. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and on behalf of the Provider _____________________________ _______________________ Paul Kleever, Executive Director Date For and on behalf of Orange County Government _______________________________ ________________________ Bonnie Hammersley, County Manager Date DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 9/24/2021 9/27/2021 Orange County Outside Agency Performance Agreement Page 10 of 13 Rev.9/21 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: Charles House Party/Vendor Contact Person: Paul Kleever Contact Phone: 919-967-7570 Party/Vendor Address: 7511 Sunrise Rd, City Chapel Hill State: NC Zip: 27514 Department: Aging Amount: $23363 Purpose: Outside Agencies Budget Code(s): 10495050-710029 Vendor # 800031 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date July1, 2021 Approved by Board Yes No Agenda Date: 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: Department Director’s Signature ________________________________________ Date: ________ 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 sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ 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:_________ DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 9/25/2021 9/27/2021 9/27/2021 9/27/2021 Orange County Outside Agency Performance Agreement Page 11 of 13 Rev.9/21 Exhibit A Provider’s Outside Agency Application DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 Orange County Outside Agency Performance Agreement Page 12 of 13 Rev.9/21 Exhibit B Provider’s Revised Scope of Services and Program Budget DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 Orange County Outside Agency Performance Agreement Page 13 of 13 Rev.9/21 ATTACHMENT “A” Orange County Certifications – FY 20 - Outside Agency Performance Agreement Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title, residential address; phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing, with the name, physical address, mailing address and if possible, phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a separate sheet of paper. Alignment with Organization’s Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. Certified by: _______________________ Title: __________________________ Date: ___________ (Provider’s Signature) DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 9/24/2021 ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED? INSR ADDL SUBRLTR INSD WVD PRODUCER CONTACTNAME: FAXPHONE(A/C, No):(A/C, No, Ext): E-MAILADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATIONAND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER: $ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH-STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 7/13/2021 (919) 636-3252 2 Charles House Association 7511 Sunrise Road Chapel Hill, NC 27514 A 1,000,000 X PHPK2129948 5/10/2021 5/10/2022 100,000 5,000 1,000,000 3,000,000 3,000,000 1,000,000A PHPK2129948 5/10/2021 5/10/2022 1,000,000A PHUB721449 5/10/2021 5/10/2022 1,000,000 B WC23000-2020 6/25/2021 6/25/2022 500,000 500,000 500,000 A E&O PHPK2129948 5/10/2021 Each Claim 1,000,000 A E&O PHPK2129948 5/10/2021 5/10/2022 Aggregate 3,000,000 Certificate holder is added as Additional Insured as respects General Liability as required by written contract. Orange County Government P.O. Box 8181 Hillsborough, NC 27278 CHARHOU-01 VDECAMP Titan Risk Consultants LLC107 Conner Drive, Suite 225Chapel Hill, NC 27514 Victoria DeCamp v.decamp@titanriskconsultants.com Philadelphia Indemnity Insurance Company Carolina Mutual Insurance Company 5/10/2022 X X X X X X DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 CHARLES HOUSE ASSOCIATION BOARD OF DIRECTORS Beth Tillman, Vice President (Second term ends: 10/23) Attorney Tillman, Whichard & Cagle, PLLC 919-402-1740 95 Glen Eden Ct. Chapel Hill, NC 27516 Suzanne Kalbas, Secretary (Second term ends: 10/22) Community Leader 75001 Miller Chapel Hill, NC 27517 Robert Spransy, Treasurer (First term ends: 10/21) CPA 257 Abercorn Circle Chapel Hill, NC 27516 Cell: 919-672-3339 Melvin S. Hurston, Past President (Second term ends: 1/22) Senior Vice President Professional & Support Services UNC Hospitals 984-974-4423 10003 Hammock Bend Chapel Hill, NC 27517 Jesse Basnight, Jr. (Second term ends: 10/22) Vice President, S.H. Basnight & Sons 919-942-3158 204 Cobblestone Dr. Chapel Hill, NC 27516 Anna Beeber (First term ends: 9/21) Associate Professor School of Nursing, UNC 919-843-9489; (Cell) 919-610-8412 110 Purple Leaf Place Carrboro, NC 27510 Brad Fox (Second term ends: 1/22) President, Medical Claims Rx, Inc. 919-942-7211 3011 Silas Lane Hillsborough, NC 27278 Nancy Jones (Second term ends: 10/22) Retired Public School Teacher 115 Essex Dr. Chapel Hill, NC 27514 919-967-1414 Joel I. Levy (Second term ends: 10/22) Joel I. Levy, CPA, PLLC 919-3707631 76505 Rice Chapel Hill, NC 27517 Julia Lunsford, MD (First term ends: 7/21) Clinical Asst. Professor Dept. of Psychiatry UNC Healthcare/School of Medicine 984-974-3853 357 Tenney Circle Chapel Hill, NC 27514 Paul Klever, Executive Director Charles House Association 7511 Sunrise Road Chapel Hill, NC 27514 919-967-7570 paul@charleshouse.org DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267 DocuSign Envelope ID: 9C0D1243-D858-43C4-ADB1-456357F3F267