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2021-631-E-Health-Table Ministries-Outside Agency Agreement
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 Table Ministries, Inc., a not-for-profit corporation, located at 209 E. Main Street, Carrboro, North Carolina 27510 (“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 $15,000. 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 $3,750. 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: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 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: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 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: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 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: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 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: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 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 Table Ministries, Inc. Attention: Kimberlee Quatrone Attention: Ashton C. Tippins P.O. Box 8181 Address: 209 E. Main Street Hillsborough, NC 27278 Carrboro, NC 27510 Email:kquatrone@orangecountync.gov Email: actippins@tablenc.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 _____________________________ _______________________ Ashton C. Tippins, Executive Director Date For and on behalf of Orange County Government _______________________________ ________________________ Bonnie Hammersley, County Manager Date DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 10/27/2021 10/27/2021 Orange County Outside Agency Performance Agreement Page 7 of 10 Rev.10/21 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: Table Ministries, Inc. Party/Vendor Contact Person: Ashton C. Tippins Contact Phone: 919- 636-4860 Party/Vendor Address: 209 E. Main Street City Carrboro State: NC Zip: 27510 Department: Health Amount: $15,000 Purpose: Outside Agency Agreement Budget Code(s): 10495050-720116 Vendor # 800791 (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 updated 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: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 10/27/2021 10/27/2021 10/27/2021 10/27/2021 Cover Page P a g e 6 o f 23 COVER PAGE Applicant Contact Information Applicant Organization’s Legal Name: Table Ministries, Inc. Applicant Organization’s Physical Address: 209 E. Main Street, Carrboro, NC 27510 Applicant Organization’s Mailing Address: same as above Applicant Organization’s Web Address: www.tablenc.org Executive Director: Ashton C. Tippins Telephone Number: (919)636-4860 E-Mail: actippins@tablenc.org Tax ID Number: 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 Food to Front Door: Food, supplies, program staff, operations, & space 15000 15000 15000 45000 Totals 15000 15000 15000 45000 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Cover Page P a g e 7 o f 23 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. Signature: 1/13/21 Executive Director Date Signature: 1/13/21 Board Chairperson Date The pandemic has created unique challenges for our county’s most vulnerable populations. In the midst of the uncertainty, TABLE is continuing to provide the stability of sufficient nutritious food. The very first week that schools closed in March 2020, TABLE shifted our operations to deliver directly to the homes of 500 of our children knowing that time out of school would create financial and nutritional challenges for our kids and their families. Staff began to gather the addresses of more of our children, supplement additional nutritious food, and, ultimately, delivered to about 685 kids without interruption throughout the entire spring and summer 2020. A result of our shifted model was improved communication with our families. Our desire is to continue to foster that communication in order to understand the needs of our kids and better serve them and their families by: 1) improving food access and demonstrating respect for our families by piloting a shopping experience, 2) integrating interactive nutrition education to promote healthier lifestyles among our kids, and 3) identifying ways we can serve as a bridge to support a family’s own stability, well-being, and their child(ren)’s future. In order to continue to meet the needs of our 725 kids and their families, we will continue delivering weekly nutritious foods directly to the doorsteps of our kids. Specifically, funds will be used to: • Purchase nutritious food • Support staff needs to execute programming and develop relationships with families • Support space needed to process and deliver food • Pilot a new food access initiative that allows families to “shop” online and have food delivered to their door As our world continues to change, TABLE remains constant and assure our kids that they are thought of and cared for! EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Cover Page P a g e 8 o f 23 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: 1/13/21 Executive Director Date Signature: 1/13/21 Board Chairperson Date EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Program information P a g e 9 o f 23 AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year): 11/2007 2. Agency’s Purpose/Mission (no more than a few sentences): TABLE’s mission is to provide healthy, emergency food aid every week to preschool, elementary, middle, and high school children living in Chapel Hill, Carrboro, and neighboring Orange County communities as well as provide nutrition education to children in our area. 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). Since its founding, TABLE has had a successful history of surpassing our goals. From 12 children served in 2008 to 725+ in 2020-21, we continue to grow, accommodate changing needs, and meet gaps in our community. Some of our greatest accomplishments include adapting operations during a pandemic and closed school, sourcing nutritious food when stocks were low, partnering with a local farm to source organic produce, and raising necessary funds to improve operations and begin identifying a new, permanent space. Experienced staff, a solid volunteer and generous donor base give TABLE a highly favorable outlook headed into 2021-22. 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: 4 # of FTE – Part-Time Paid Positions: 2 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 5. Program Name: Food to Front Door (A Food Access Initiative) Program Primary Contact and Title: Laura Dille Telephone Number: (9190636-4860 E-Mail: ldille@tablenc.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) EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Program information P a g e 10 o f 23 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 374 346 378 403 Women 361 319 348 372 Nonbinary/Genderqueer N/A N/A N/A N/A Self-Describe N/A N/A N/A N/A Unknown 15 22 24 25 Total 750 686* 750 800 Race and Ethnicity Black or African-American 214 188 206 219 American Indian or Alaska Native 1 0 0 0 Asian 111 94 103 110 White 285 263 288 307 Native Hawaiian or other Pacific Islander 0 0 0 0 Two or more races 57 53 58 62 Some other race 16 3 3 3 Unknown 66 72 92 99 Total 750 686* 750 800 Of the above, how many Hispanic/Latino 228 221 242 258 Of the above, how many non-Hispanic/Latino 456 393 430 458 Unknown 66 72 78 84 Total 750 686* 750 800 Age 0-5 years 120 118 129 138 6-18 years 548 539 589 629 19-50 years 0 0 0 0 51+ years 0 0 0 0 Unknown 82 29 32 33 Total 750 686* 750 800 Geographic Location Town of Chapel Hill 404 428 468 499 Town of Carrboro 188 178 195 208 Orange County ( Outside of Chapel Hill/Carrboro) 145 75 82 87 Outside of Orange County 4 0 0 0 Unknown 9 5 5 6 Total 750 686* 750 800 Income EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Program information P a g e 11 o f 23 Low-income (80% of the Area Median Income and Below) Please see income table in the attachments 484 (unknown TBD) 449 (232 unknown) 491 (unknown TBD) 524 (unknown TBD) Total 0 686* 750 800 *Please note that we actually delivered to 723 kids weekly prior to school closures in 2020. These numbers represent the majority of 2019-20. 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 $607,245 $1,051,733 $1,175,163 Total # of Individuals 723 750 800 Cost Per Individual $839.90* $1,402.31* $1,468.95* * These numbers reflect a shift in our operations to: 1) provide more food each week, 2) provide additional local, organic produce, 3) integrate nutrition education lessons, activities, & tools into our food access programming, and 4) continue to further develop our program to meet the needs of our kids – including allowing families to select they food they’d like to receive. 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: Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes ✓ Residents Increase their livelihood security ✓ Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Insert Intermediate Result here. 2.1 Residents access the most appropriate social safety net services 3.2 Residents demonstrate new healthy lifestyle behaviors RESULTS Actual 2019-20 Projected 2020-21 Projected 2021-22 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Program information P a g e 12 o f 23 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). Insert Performance Indicator here. # of program participants that receive food assistance 723 participants received food assistance 750 participants receive food assistance 800 participants receive food assistance % of program participants that consume fresh food 59% of respondents say their child is willing to try more fruits and vegetables than they previously would have 65% of respondents say their child is willing to try more fruits and vegetables than they previously would have 30% of respondents say their child regularly consumes more fruits & vegetables than they previously would have % of people reporting healthier functionality and lifestyle behaviors such as improved nutrition 56% of respondents say they eat healthier because of the food TABLE provides. 60% of respondents say they eat healthier because of the food TABLE provides. 30% of respondents say they choose healthier food options when purchasing food due to their participation in TABLE’s programs. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Outside Agencies/Human Services Program information P a g e 13 o f 23 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. Food and Nutritional Services 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 equivale nce. • Please ensure your performance measures are outcome based and not outputs. Program Goal # 1 Children eat, taste, or are exposed to more fresh food than they would without TABLE. Performance Measure (How will you accomplish your goal?) Annual Survey Actual Results (Outcome) Ending FY19-20 59% of respondents say their child is willing to try more fruits and vegetables than they previously would have Projected Results (Outcome) Ending FY2021 65% of respondents say their child is willing to try more fruits and vegetables than they previously would have Projected Results (Outcome) Ending FY2022 30% of respondents say their child regularly consumes more fruits & vegetables than they previously would have Program Goal # 2 Rate of food insecurity decreases among TABLE participants and they can rely on steady food assistance. Performance Measure (How will you accomplish your goal?) Survey questions based on federal 6-item questionnaire to determine level of food security Actual Results (Outcome) Ending FY19-20 13% rated as very low food security Projected Results (Outcome) Ending FY2021 11% rated as very low food security _________________ EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Outside Agencies/Human Services Program information P a g e 14 o f 23 Projected Results (Outcome) Ending FY2022 10% rated as very low food security Program Goal # 3 Parents report healthier lifestyle behaviors such as improved nutrition. Performance Measure (How will you accomplish your goal?) Annual Survey Actual Results (Outcome) Ending FY19-20 56% of respondents say they eat healthier because of the food TABLE provides. Projected Results (Outcome) Ending FY2021 60% of respondents say they eat healthier because of the food TABLE provides. Projected Results (Outcome) Ending FY2022 30% of respondents say they choose healthier food options when purchasing food due to their participation in TABLE’s programs. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Program information P a g e 15 o f 23 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. As a result of COVID-19 and remote learning, fewer families signed up for subsidized school meals. Yet, families are experiencing unique challenges, which may mean our community's children are more vulnerable than ever. In order to support our kids and their families, TABLE adapted our operations to deliver directly to the doorstep of each of our children. We continue to operate and identify ways we can most effectively support our kids. Our families report the following on our annual survey: • 48% wish to continue receiving food from TABLE because it gives them access to nutritious foods and produce they could otherwise not access. • 82% report that receiving food from TABLE eases a financial burden for their family. One parent said: “My family and I would like to thank you for your efforts and support during the pandemic. Also I wanted to let you know that I have enjoyed the food modifications with more fruits and vegetables. Thank you!” 2. What methods/tools will your organization use to evaluate the proposed program’s effectiveness? Please include specific examples, such as a logic model. For all our programs, TABLE utilizes formal surveys, phone calls with parents, focus groups, and school social worker feedback to evaluate our effectiveness. We are also in the process of developing pilot programs and engaging participants in those programs to determine how we can continue to strengthen our impact and effectiveness. 3. Please briefly describe how your proposed programs aligns with evidence-based approaches to addressing human service need(s). According to Feeding America’s 2012 evaluation, best practices of a backpack program include: 1) discrete distribution of nutritious items; 2) distribution of the items prior to the weekend, and 3) items that the recipients can prepare on their own. Since the start of the pandemic, our model shifted to delivery of healthy food directly to the doorsteps of our children. While we are still identifying the best ways to serve our kids long-term, feedback from families suggests that our current program model positively impacts our kids and their families by supplementing food and nutritional needs. 4. Please describe one to three key partnerships/collaborations that add the most value to the success of the proposed programs. Wildflower Lane Farm – TABLE partners with a local farmers to provide fresh, local, high-quality produce to our children and their families at low cost to TABLE. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Program information P a g e 16 o f 23 Family Success Alliance – provides us with valuable connections, guidance, and grant opportunities. Our partnership helps prevent us from operating in a silo and allows us to collaborate with a number of local nonprofits. Weaver Street Market – helps to connect TABLE with the community, raises funds for us, provides food, and provides event space for us. Our friends at WSM also critically think about how we can alleviate local hunger. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) EXHIBIT “B” Scope of Services – FY 2021-2022 Outside Agency Performance Agreement Agency Name: TABLE, Inc. Program Name: TABLE@home Funding Award: 15000 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. • Delivery of nutritious food to kids in Orange County every week. • Improve and scale food access pilot program for families to order food for their family. • 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 Children eat, taste, or are exposed to more fresh food than they would without TABLE. 30% regularly consume fruits & veggies Rate of food insecurity decreases among TABLE participants and they can rely on steady food assistance. 11% rated as very low food security Expense Description Amount Purchase nutritious food 7500 Support staff needs to execute programming and develop relationships with families 3000 Space 3000 Supplies 1500 DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 Executive Director 10/27/2021 Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) Performance Measures Anticipated Results Parents report healthier lifestyle behaviors such as improved nutrition. 30% choose healthier options when purchasing food due to participation in TABLE programming DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 10/27/2021Executive Director Orange County Outside Agency Performance Agreement Page 10 of 10 Rev.10/21 ATTACHMENT “A” Orange County Certifications – FY 2021-2022 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: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 10/27/2021Executive Director The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE LOCJECTPRO-POLICY GEN'L AGGREGATE LIMIT APPLIES PER: OCCURCLAIMS-MADE COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence)$DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $RETENTIONDED CLAIMS-MADE OCCUR $ AGGREGATE $ EACH OCCURRENCE $ UMBRELLA LIAB EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSRLTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)LIMITS PERSTATUTE OTH-ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNEDAUTOSAUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE $ $ $ $ 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. INSD ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) OTHER: THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: INSURED PHONE(A/C, No, Ext): PRODUCER ADDRESS:E-MAIL FAX(A/C, No): CONTACTNAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1/10/2020 AssuredPartners of NC,LLC -Raleigh 4505 Falls of Neuse Road,Suite 350 Raleigh NC 27609 Select Business Unit 844-206-9394 sbu.servicenc@assuredpartners.com Cincinnati Insurance Company 10677 TABLMIN-01 Table Ministries Inc 209 E Main St Carrboro NC 27510 932998092 A X 1,000,000 X 100,000 10,000 1,000,000 2,000,000 ETD 0496055 7/9/2019 7/9/2022 2,000,000 A Property Sexual Abuse &Molestation ETD 0496055 7/9/2019 7/9/2022 BPP Aggregate 25,000 2,000,000 Orange County PO Box 8181 Hillsborough NC 27278 DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95 DocuSign Envelope ID: 6AACAE3D-76C8-46BA-8DCC-C71ED367AD95