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2021-595-E-OC Rape Crisis Center-Outside Agency
Orange County Outside Agency Performance Agreement Revised 10/2021 Page 1 of 10 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 Orange County Rape Crisis Center, a not-for-profit corporation, located at 1506 East Franklin Street, Suite 200, 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 Provider 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 forth 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 $62,000. 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 $15,500. 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: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Orange County Outside Agency Performance Agreement Page 2 of 10 Rev.10/21 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. DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Orange County Outside Agency Performance Agreement Page 3 of 10 Rev.10/21 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. 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 (Quintana Stewart) 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 DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Orange County Outside Agency Performance Agreement Page 4 of 10 Rev.10/21 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 • 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. DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Orange County Outside Agency Performance Agreement Page 5 of 10 Rev.10/21 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 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. 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 DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Orange County Outside Agency Performance Agreement Page 6 of 10 Rev.10/21 enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. l. 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. m. 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 OC Rape Crisis Center Attention: Kimberlee Quatrone Attention: Rachel Valentine P.O. Box 8181 Address: PO Box 4722 Hillsborough, NC 27278 Chapel Hill, NC 27515 Email:kquatrone@orangecountync.gov Email: rvalentine@ocrcc.org n. 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 _____________________________ _______________________ Rachel Valentine, Executive Director Date For and on behalf of Orange County Government _______________________________ ________________________ Bonnie Hammersley, County Manager Date DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 10/20/2021 10/22/2021 Orange County Outside Agency Performance Agreement Page 7 of 10 Rev.10/21 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: OC Rape Crisis Center Party/Vendor Contact Person: Rachel Valentine Contact Phone: 919- 968-4647 Party/Vendor Address: 1506 E. Franklin St., Ste. 200 City Chapel Hill State: NC Zip: 27514 Department: Health Amount: $62,000 Purpose: Outside Agency Budget Code(s): 10495050-710009 Vendor # 800015 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 7-1-2021 Approved by Board Yes No Agenda Date: June 15, 2021 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: Waiting on new template. 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: BEA4B8BB-13B7-4322-9698-A424692E9FD4 10/21/2021 10/21/2021 10/21/2021 10/22/2021 Cover Page P a g e 6 o f 31 COVER PAGE Applicant Contact Information Applicant Organization’s Legal Name: Orange County Rape Crisis Center Applicant Organization’s Physical Address: 1506 E. Franklin Street, Suite #200 Chapel Hill, NC 27514 Applicant Organization’s Mailing Address: PO Box 4722, Chapel Hill, NC 27515 Applicant Organization’s Web Address: www.ocrcc.org Executive Director: Rachel Valentine Telephone Number: 9199684647 E-Mail: rvalentine@ocrcc.org Tax ID Number: 58-1356356 Funding Request Please list all Fiscal Year 2022 Human Services (HS) funding requested for all programs and the proposed use of funds (please list program name only) Program Carrboro - HS Chapel Hill - HS Orange County-HS Total Ex. Youth Afterschool Program Operations or Personnel $10,000 Operations $15,000 Personnel $5,000 Operations $30,000 Rape Crisis Victim’s Services Personnel and Operations $10,000 $20,500 $26,000 $56,500 Community Engagement for Safe Kids Personnel and Supplies $7,000 $11,000 $22,000 $40000 Pro Bono Counseling Network Personnel 3000 8,000 14000 $25,000 Totals $20,000 $39,500 $62,000 121,500 Briefly explain your proposed use of funds: 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. We propose to use these funds in support of comprehensive mental and behavioral health supports for survivors of sexual violence throughout Orange County. Services include maintenance of three bilingual 24-hour crisis lines, 24-hour crisis intervention and medical accompaniment, case management and court advocacy as well as training to provide culturally competent services to underserved communities; outreach, training, and education activities engaging tens of thousands of residents to create a safer community free of child sexual abuse, sexual assault and human trafficking. Finally, this year the OCRCC intends to use these finds to launch the Pro Bono Counseling Network to connect low income residents with free and sliding scale therapy services. DocuSign Envelope ID: A1C5195D-6140-4BAA-8624-408DB5CDAEAA EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Cover Page P a g e 7 o f 31 Signature: Executive Director Date Signature: Board Chairperson Date DocuSign Envelope ID: A1C5195D-6140-4BAA-8624-408DB5CDAEAA 1/13/2021 | 4:09 PM EST 1/13/2021 | 8:24 AM PST EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Cover Page Page 8 of 31 DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON‐DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates. YES NO a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? c) Current beneficiaries of the program for which funds are being requested? d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON‐DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti‐discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: Executive Director Date Signature: Board Chairperson Date DocuSign Envelope ID: 5E9D09D4-7DCD-4BC4-A752-82DC118812AC 9/23/2021 | 11:19 AM EDT 9/23/2021 | 11:18 AM EDT EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 9 of 31 AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year): 12/1978 2. Agency’s Purpose/Mission (no more than a few sentences): Our mission is to stop sexual violence and its impact through support, education, and advocacy. We envision a world free from sexual violence and all other forms of oppression. 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). The OCRCC has provided crisis intervention for survivors of sexual violence since 1974. Both qualitative and quantitative data show the high success level of our client services. Launched in 1982, our Community Education program is one of the longest‐standing in the country, and we have enjoyed a close relationship with local school districts. The OCRCC has been in receipt of Human Services funding since 2004 and has maintained a stellar record of service delivery within provided timeframes and budgets. The agency devotes administrative staff time to maintaining compliance with all budgetary and programmatic regulations related to our grants. 4. Living Wage: Does this agency pay permanent employees a minimum living wage? (Yes / No) Yes If yes, is this agency an Orange County Living Wage Certified Employer? Yes If no, please briefly explain. Schedule of Positions: # of FTE – Full‐Time Paid Positions: 16 # of FTE – Part‐Time Paid Positions: 11 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 10 of 31 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 5. Program Name: Rape Crisis Victim’s Services Program Primary Contact and Title: Rachel Valentine, Executive Director Telephone Number: 919‐968‐4647 E‐Mail: rvalentine@ocrcc.org 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) The OCRCC supports sexual violence survivors through our 24‐Hour Help Lines (phone, text, chat‐ all bilingual in English and Spanish), accompaniment, support groups, and therapy. We provide case management for survivors with basic needs concerns. These services are an integral part of a robust human services infrastructure supporting the well‐being of all residents’ We help clients access the most appropriate social safety net services1, behavioral health services2, and support resident in developing new healthy lifestyle behaviors3. 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 2019‐ 2020 Actual 2019‐20 Projected 2020‐21 Revised Projection 2020‐21 Projected 2021‐22 Gender Men 95 47 125 45 55 Women 460 275 575 375 395 Nonbinary/Genderqueer 160 6 250 25 35 Self‐Describe 0 0 0 0 0 Unkown 0 241 0 250 210 Total 715 569 950 695 695 Race and Ethnicity Black or African‐American 40 29 75 35 60 American Indian or Alaska Native 2 1 0 0 0 1 TOCH/C Results Framework Objective 2.1 2 TOCH/C Results Framework Objective 3.1 3 TOCH/C Results Framework Objective 3.2 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 11 of 31 Asian 10 4 10 5 5 White 185 69 250 190 255 Native Hawaiian or other Pacific Islander 0 0 0 0 0 Two or more races/Other 28 77 80 75 125 Unknown 450 389 535 390 250 Total 715 569 950 695 695 Of the above, how many Hispanic/Latino 90 70 175 90 90 Of the above, how many non‐Hispanic/Latino 625 499 775 605 605 Total 715 569 950 695 695 Age 0‐5 years 0 2 0 0 0 6‐18 years 25 9 50 15 15 19‐50 years 225 111 350 250 370 51+ years 40 24 75 50 60 Unknown 425 423 475 380 250 Total 715 569 950 695 695 Geographic Location Town of Chapel Hill 190 112 250 150 175 Town of Carrboro 45 28 100 45 40 Orange County ( Outside of Chapel Hill/Carrboro) 125 20 200 150 185 Outside of Orange County 60 94 100 75 45 Unknown 295 315 300 275 250 Total 715 569 950 695 695 Income Low‐income (80% of the Area Median Income and Below) Please see income table in the attachments Not tracked Not tracked Not Tracked Not Tracked Not Tracked Total Not tracked Not tracked Not Tracked Not Tracked Not Tracked Not tracked Not tracked Not Tracked Not Tracked Not Tracked 715 569 950 695 695 Note: Projections here are copied directly from our FY 20‐21 application, which was completed prior to the onset of COVID‐19. The pandemic has had a significant impact on our service numbers and we do not believe these projections are accurate or reasonable any longer. I have included an additional column in this chart to show our current projections based on data from the first 6 months of the year, anticipating that conditions related to COVID‐19 are unlikely to change significantly before the end of the current FY. 8. Cost Per Individual EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 12 of 31 This cost per individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2019‐20 Projected 2020‐21 Projected 2021‐22 Total Cost of Program 638,451.25 859,101.39 689,800 Total # of Individuals 569 950/ 695 695 Cost Per Individual 1,122 904.31/ 1236 992.51 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: Rape Crisis Victim’s Services Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes X Residents Increase their livelihood security Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Intermediate Result 2.1: Residents access the most appropriate social safety net services RESULTS Actual 2019‐20 Projected 2020‐21 Projected 2021‐22 Performance Indicators (Please choose at least one performance indicator to report on from the Results Framework, and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as needed, listing one per row). 1. % and # Client satisfaction rates 1. Not measured 1. 200 (85%) of support group, therapy and case management clients will report satisfaction with the services received. 1. 225 (85%) of support group, therapy and case management clients will report satisfaction with the services received. 2. % and # of individuals that receive abuse and neglect prevention and response services 2. 569 (100%) of residents that contact the agency received abuse response services 2. 695 (100%) of residents that contact the agency will receive abuse response services 2. 695 (100%) of residents that contact the agency will receive abuse response services EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 13 of 31 Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes Residents Increase their livelihood security X Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Intermediate Result 3.1: Residents access basic health care services (primary, behavioral, dental) RESULTS Actual 2019‐20 Projected 2020‐21 Projected 2021‐22 Performance Indicators (Please choose at least one performance indicator to report on from the Results Framework, and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as needed, listing one per row). 1. % and # of program participants who report new, improved, or restored social connections 1. Not measured 1. 59 (85%) of support group participants will report decreased feelings of isolation 1. 63 (85%) of support group participants will report decreased feelings of isolation 2. % and # of program participants who meet one wellness goal 2. 65 (95%) of support group and therapy clients met one wellness goal. 2. 85 (85%) of case management and therapy clients will meet at least one self- identified wellness goal. 2. 102 (85%) of case management and therapy clients will meet at least one self- identified wellness goal. PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 5. Program Name: Community Engagement for Safe Kids Program Primary Contact and Title: Rachel Valentine, Executive Director Telephone Number: 919‐968‐4647 E‐Mail: rvalentine@ocrcc.org 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) The OCRCC will provide safety education programs to youth and adults. Our programs address Adverse Childhood Experiences (ACEs) and assists local schools with identifying, reporting and supporting families experiencing sexual abuse. Most programs take place within local schools to educate youth and adults across all demographics in OC. We focus on services to underserved populations, including low‐income families, children with disabilities, and students facing challenges in school. Our prevention and support services form a EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 14 of 31 part of the community network of basic human services that promote the wellbeing of all residents4 and help students improve their health outcomes5. 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 2019‐ 2020 Actual 2019‐20 Projected 2020‐21 Projected 2021‐22 Gender Men 6978 4939 7020 6020 Women 7559 5306 7613 6650 Nonbinary/Genderqueer 763 541 767 480 Self‐Describe 0 0 00 Unknown 0 152 00 Total 15300 10828 15400 13150 Race and Ethnicity Black or African‐American 1805 1624 1817 1220 American Indian or Alaska Native 92 65 92 65 Asian 1270 866 1278 1050 White 11720 7904 11796 10650 Native Hawaiian or other Pacific Islander 15 10 15 15 Two or more races/Other 398 282 400 150 Unknown 0 77 00 Total 15300 10828 15400 13150 Of the above, how many Hispanic/Latino 1315 931 1324 1800 Of the above, how many non‐Hispanic/Latino 13985 9897 14076 11350 Total 15300 10828 15400 13150 Age 0‐5 years 2000 262 2000 250 6‐18 years 11000 7212 11000 7050 19‐50 years 2300 3354 2400 3050 51+ years 0 0 0 150 Unknown 2650 Total 15300 10828 15400 13150 Geographic Location Town of Chapel Hill 7250 4958 7300 6300 Town of Carrboro 1800 531 1800 1300 4 OC BOCC Goals 5 TOCH Results Framework Strategic Objective 3 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 15 of 31 Orange County ( Outside of Chapel Hill/Carrboro) 4500 2876 4450 3000 Outside of Orange County 1500 2463 1600 1300 Unknown 250 0 250 1250 Total 15300 10828 15400 13150 Income Low‐income (80% of the Area Median Income and Below) Please see income table in the attachments Not tracked Not tracked Not Tracked Not Tracked Total Not tracked Not tracked Not Tracked Not Tracked Not tracked Not tracked Not Tracked Not Tracked 15300 10828 15400 13150 We are not able to track education programs based on Gender or Ethnicity since they typically have large, mixed audiences. Entries for gender and race/ethnicity are based on demographic estimates for the county. With the vast majority of our programs taking place in the local school districts, we can assume that our outreach numbers reflect county-wide demographic data. Figures for Geographic Location are determined based on where the program was delivered (e.g., a program at Carrboro Elementary School will place all participants in the Town of Carrboro). 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 2019‐20 Projected 2020‐21 Projected 2021‐22 Total Cost of Program 231344 270300 228085 Total # of Individuals 10828 15400 13150 Cost Per Individual 21.36 17.55 17.35 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: Community Engagement for Safer Kids Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes X Residents Increase their livelihood security Residents improve their health outcomes EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 16 of 31 Intermediate Result (please choose one from the Results Framework) Intermediate Result 2.1: Residents access the most appropriate social safety net services RESULTS Actual 2019‐20 Projected 2020‐21 Projected 2021‐22 Performance Indicators (Please choose at least one performance indicator to report on from the Results Framework, and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as needed, listing one per row). % and # of individuals that receive abuse and neglect prevention and response services 10282 (100%) of participants in education programs received abuse and neglect prevention services. 15,400 (100%) of participants in education programs will receive abuse and neglect prevention services. 13,150 (100%) of participants in education programs will receive abuse and neglect prevention services. Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes Residents Increase their livelihood security X Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Intermediate Result 3.2: Residents demonstrate new healthy lifestyle behaviors RESULTS Actual 2019‐20 Projected 2020‐21 Projected 2021‐22 Performance Indicators (Please choose at least one performance indicator to report on from the Results Framework, and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as needed, listing one per row). % and # of program participants who demonstrate new, improved, or restored social skills 91% (61/67) of teachers and counselors that receive OCRCC SafeTouch programs reported an increase in student awareness of personal safety and protection against sexual violence 90 % (61) of teachers and counselors that receive OCRCC SafeTouch programs reported an increase in student awareness of personal safety and protection against sexual violence 90 % (61) of teachers and counselors that receive OCRCC SafeTouch programs reported an increase in student awareness of personal safety and protection against sexual violence EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 17 of 31 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 5. Program Name: Pro Bono Counseling Network Program Primary Contact and Title: Rachel Valentine, Executive Director Telephone Number: 919‐968‐4647 E‐Mail: rvalentine@ocrcc.org 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) Discontinued in 2019 following a restructuring at previous host agency, the OCRCC seeks to re‐ establish the Pro Bono Counseling Network as a permanent program of the agency. The PBCN provides high‐quality counseling services free of charge to underinsured residents and arranges personalized referrals to low‐cost, sliding scale, or subsidized services for all those seeking assistance, filling service gaps in the human services infrastructure6. The target population is low‐ income and underinsured residents, and the objective is to ensure all residents have access to behavioral care7 regardless of income or insurance status. 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 2019‐ 2020 Actual 2019‐20 Projected 2020‐21 Projected 2021‐22 Gender Men 10 Women 45 Nonbinary/Genderqueer 5 Self‐Describe Unkown Total 60 Race and Ethnicity Black or African‐American 8 American Indian or Alaska Native 0 Asian 1 White 35 Native Hawaiian or other Pacific Islander 0 Two or more races/Other 5 6 OC BOCC Goals 7 TOCH Results Framework Strategic Objective 3.1 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 18 of 31 Unknown 11 Total 60 Of the above, how many Hispanic/Latino 10 Of the above, how many non‐Hispanic/Latino 50 Total 60 Age 0‐5 years 0 6‐18 years 5 19‐50 years 45 51+ years 5 Unknown Total 60 Geographic Location Town of Chapel Hill 15 Town of Carrboro 10 Orange County ( Outside of Chapel Hill/Carrboro) 25 Outside of Orange County 10 Unknown Total 60 Income Low‐income (80% of the Area Median Income and Below) Please see income table in the attachments 60 Total 60 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 2019‐20 Projected 2020‐21 Projected 2021‐22 Total Cost of Program 25000 Total # of Individuals 60 Cost Per Individual 416 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. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 19 of 31 Program Name: Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes Residents Increase their livelihood security X Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Residents access basic health care services (primary, behavioral, dental) RESULTS Actual 2019‐20 Projected 2020‐21 Projected 2021‐22 Performance Indicators (Please choose at least one performance indicator to report on from the Results Framework, and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as needed, listing one per row). % and # of program participants that report they have access to behavioral care n/a n/a 60 (85% of those who contact the agency for services) will gain access to high quality mental health care free of charge through the PBCN. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Outside Agencies/Human Services Program information P a g e 21 of 31 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. Program Goal # 1 Supportive services from OCRCC will enhance the wellbeing of survivors of sexual violence Performance Measure (How will you accomplish your goal?) Survivors will be supported in learning new coping skills to assist them in dealing with trauma symptoms through support groups and individualized case management. Actual Results (Outcome) Ending FY19-20 95% (65/69) of support group and therapy clients met one wellness goal. Projected Results (Outcome) Ending FY2021 85% (85/100) of case management, support group and therapy clients will meet at least one self‐identified wellness goal. Projected Results (Outcome) Ending FY2022 85% (102/120) of case management, support group and therapy clients will meet at least one self‐identified wellness goal. Program Goal # 2 Students participating in SafeTouch programs at local elementary schools will increase their awareness of safety and privacy rights as a result of our program. Performance Measure (How will you accomplish your goal?) Counselors and teachers will report an increase in student awareness of personal safety and protection against sexual violence in post‐program surveys. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Outside Agencies/Human Services Program information P a g e 22 of 31 Actual Results (Outcome) Ending FY19-20 98% (85/87) of teachers and counselors reported that the program increased student awareness of personal safety and violence prevention. Projected Results (Outcome) Ending FY2021 At least 90% (78/87) of teachers and counselors will report an increase in student awareness of personal safety and protection against sexual violence. Projected Results (Outcome) Ending FY2022 At least 90% (78/87) of teachers and counselors will report an increase in student awareness of personal safety and protection against sexual violence. Program Goal # 3 Low‐Income and Underinsured Residents will gain access to free counseling services. Performance Measure (How will you accomplish your goal?) Residents seeking counseling services will be provided with personalized referrals and warm introductions to providers in the PBCN or other eligible services. Actual Results (Outcome) Ending FY19-20 n/a Projected Results (Outcome) Ending FY2021 n/a Projected Results (Outcome) Ending FY2022 85% (60/70) residents who seek pro bono counseling services will be connected with an appropriate referral. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 23 of 31 Community Impact Award If you are applying for the Town of Chapel Hill’s Community Impact Award, please provide responses to the questions below. All other applicants, please skip these questions. (Responses should not exceed 100 words per question) 1. Please describe the impact the proposed programs will have on the target population. Please include specific quantitative and qualitative data in your response. OCRCC represents a lifeline for survivors. Internal data demonstrates that 88‐90% of clients decrease PTSD symptom severity and increase coping skills. Students in our prevention programs overwhelmingly (90%+) report increased safety skills and awareness. We have assisted over 500 families in the aftermath of sexual abuse that was discovered as a result of our educational intervention. Additionally, we provide pro bono clinical therapy for 3 years and have seen first‐hand that our community’s need exceeds our internal capacity. Formalizing the Pro Bono Counseling Network will increase access for residents facing significant financial barriers to mental health care. 2. What methods/tools will your organization use to evaluate the proposed program’s effectiveness? Please include specific examples, such as a logic model. All program activities are evaluated. Support group, case management and therapy client outcomes are evaluated using surveys to measure symptom severity and progress toward goals. Client contacts are tracked through a confidential database and collaboratively reviewed weekly to ensure that clients are accessing the most appropriate services. PBCN outcomes will be tracked using the same system. Education programs follow a logic model to articulate a particular theory of change related to prevention of sexual violence. Programs are evaluated using post‐program surveys to teachers and counselors (elementary) and pre‐and post‐ program surveys for middle and high school students. 3. Please briefly describe how your proposed programs aligns with evidence‐based approaches to addressing human service need(s). Social support, like that offered through our 24‐Hour Helpline and support groups services, play a critical role when healing from sexual violence. Research shows that social support can help to buffer some of the stress that sexual trauma can cause.8 Trauma therapy has been proven to reduce PTSD symptoms9; our therapists employ a variety of evidence‐based models 8 Leech & Littlefield, 2011 9 NIMH, 2016 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Program information P a g e 24 of 31 including TF‐CBT and EMDR. Educational programs aligns with best research on risk reduction and primary prevention by adhering to the CDC’s Principles of Effective Prevention and modeling interventions after evidence‐ based curricula. 4. Please describe one to three key partnerships/collaborations that add the most value to the success of the proposed programs. The Compass Center for Women & Families: Cross referrals for violence response and for shelter needs. Mutual assistance with volunteer training. Joint support groups. Joint educational programming. Shared coordination of the Orange County Domestic Violence/Sexual Assault Response Committee. Chapel Hill‐Carrboro City Schools/ Orange County Schools: The OCRCC maintains an annual (MOA) with the school districts outlining responsibilities of both parties for program delivery, parent communication, and follow‐up protocol with students who raise concerns during or immediately following a program. El Centro Hispano: Cross‐ referrals, Cross training. OCRCC’s Latino Services Coordinator maintains weekly office hours at El Centro. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) EXHIBIT “B” Scope of Services – FY 2021-2022 Outside Agency Performance Agreement Agency Name: Orange County Rape Crisis Center Program Name: Rape Crisis Victim's Services Funding Award: $26,000 Outline how the agency will spend Orange County’s funding award. Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2022. • 24 Hour Crisis intervention via 3 bilingual Helplines (phone, text and chat) • Case Management services for survivor of sexual assault • Support Group and Therapy referral Services to support ongoing mental health access 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 support group, therapy and case management clients will report satisfaction with the services received. 125 (85%) residents that contact the agency will receive abuse response services 495 (100%) support group participants will report decreased feelings of isolation 63 (85%) Expense Description Amount Program Staff Salary + Fringe 15000 Answering Service 2000 Rent 3000 Program and Office Supplies 1000 Professional Services: Bookkeeping, HR Support, Financial Audit 7000 DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Executive Director 10/20/2021 Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) EXHIBIT “B” Scope of Services – FY 2021-2022 Outside Agency Performance Agreement Agency Name: Orange County Rape Crisis Center Program Name: Community Engagement for Safe Kids Funding Award: $22,000 Outline how the agency will spend Orange County’s funding award. Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2022. • The OCRCC will provide safety education programs to youth and adults. Our programs address Adverse Childhood Experiences (ACEs) and assists local schools with identifying, reporting and supporting families experiencing sexual abuse. • • 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 participants in education programs will receive abuse and neglect prevention services. 13,150 (100%) teachers and counselors that receive OCRCC SafeTouch programs reported an increase in student awareness of personal safety and protection against sexual violence 90 % (61) Expense Description Amount Community Education Assistant Salary 15000 Professional Development for Program Staff 2000 Rent 3000 Program and Office Supplies 2000 DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 10/20/2021Executive Director Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) EXHIBIT “B” Scope of Services – FY 2021-2022 Outside Agency Performance Agreement Agency Name: Orange County Rape Crisis Center Program Name: Pro Bono Couneling Network Funding Award: $14,000 Outline how the agency will spend Orange County’s funding award. Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2022. • The PBCN provides high-quality counseling services free of charge to underinsured residents and arranges personalized referrals to low-cost, sliding scale, or subsidized services for all those seeking assistance, • • 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 residents who contact the agency for services) will gain access to high quality mental health care free of charge through the PBCN 45 (85% Expense Description Amount PBCN Coordinator Salary + Fringe 12000 Rent 2000 DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 10/20/2021Executive Director Orange County Outside Agency Performance Agreement Page 10 of 10 Rev.10/21 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: BEA4B8BB-13B7-4322-9698-A424692E9FD4 Executive Director 10/20/2021 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 6/28/2021 High &Rubish Insurance PO Box 3040 Chapel Hill NC 27515-3040 919-913-1144 919-913-1155 License#:1000008811 Philadelphia Insurance Co ORANCTY-01 Hartford Insurance Company of 37478OrangeCountyRapeCrisisCenter P O Box 4722 Chapel Hill NC 27515-4722 Hartford Bonds 1543057684 A X 1,000,000 X 100,000 5,000 1,000,000 2,000,000 Y Y PHPK2029814 10/10/2020 10/10/2021 2,000,000 A 1,000,000 X X PHPK2029814 10/10/2020 10/10/2021 B XY22WBCNY94754/24/2021 4/24/2022 500,000 500,000 500,000 A C PHSD1555522 22BDDHK0780 6/30/2021 6/3/2021 6/30/2022 6/3/2022 Dishonesty Bond Directors &Officers 300,000 1,000,000 Additional Insured:Orange County (Professional Liability limits are $1,000,000 occurrence /$2,000,000 aggregate) ORANGE COUNTY Government 200 South Cameron Street P O Box 8181 Hillsborough NC 27278 USA DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 10/20/2021 High &Rubish Insurance PO Box 3040 Chapel Hill NC 27515-3040 919-913-1144 919-913-1155 License#:1000008811 Philadelphia Insurance Co ORANCTY-01 Hartford Insurance Company of 37478OrangeCountyRapeCrisisCenter P O Box 4722 Chapel Hill NC 27515-4722 Hartford Bonds 1169295273 A X 1,000,000 X 100,000 5,000 1,000,000 2,000,000 X Y Y PHPK2333306 10/10/2021 10/10/2022 2,000,000 A 1,000,000 X X PHPK2333306 10/10/2021 10/10/2022 B XY22WBCNY94754/24/2021 4/24/2022 500,000 500,000 500,000 A C PHSD1555522 22BDDHK0780 6/30/2021 6/3/2021 6/30/2022 6/3/2022 Dishonesty Bond Directors &Officers 300,000 1,000,000 Orange County Government Risk Manager 200 S Cameron St PO Box 8181 Hillsborough NC 27278 USA DocuSign Envelope ID: BEA4B8BB-13B7-4322-9698-A424692E9FD4