HomeMy WebLinkAbout2021-660-E-Housing Dept-OCHCD-Rapid Rehousing service
ROY COOPER • Governor
MANDY COHEN, MD, MPH • Secretary
JOYCE MASSEY-SMITH, MPA •
Director, Division of Aging and Adult Services
NC DEPARTMENT OF HEALTH AND HUMAN SERVICES • DIVISION OF AGING AND ADULT SERVICES
LOCATION: 693 Palmer Drive, Taylor Hall, Raleigh, NC 27603
MAILING ADDRESS: 2101 Mail Service Center, Raleigh, NC 27699-2101
www.ncdhhs.gov • TEL: 919-855-3400 • FAX: 919-733-0443
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
DATE: November 18, 2021
TO: Corey Root
RE: 2021-22 NC Emergency Solutions Grants Program Conditional Award Notification
We are pleased to advise that the applicant below, for the 2021-22 NC Emergency Solutions Grants Program
(ESG) is approved for a conditional award. Below are the conditions for this award, responses to “Required
Actions” are due by 12pm (noon) November 19, 2021.
CONDITIONAL FUNDING INFORMATION
Applicant Orange County CoC 513
Project Type and Funding
Amount Street Outreach $
Emergency Shelter Operations $
Emergency Shelter Services $
Rapid Rehousing Financial Assistance $
Rapid Rehousing Services $ 40,526
Homeless Prevention Financial Assist $
Homeless Prevention Services $
HMIS / DV Comparable Database $
Total $ 40,526
REQUIRED ACTIONS
☒Required Action
Please complete the following forms attached:
Environmental Review Form (one form required per funded activity.
Example – if funded for RRH and Emergency Shelter, two forms must be
completed).)
Limited English Proficiency Certification
State and Federal Certifications
Additional Special Considerations:
Submit Procurement Policy
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RFA Appeals Process:
Any organization may appeal in writing, on organization letterhead, with the NC ESG Office by December 4, 2021.
The NC ESG Office then has thirty (30) days from receipt of the appeal to respond. If the applicant organization is
not satisfied with the proposed resolution from the State of North Carolina DHHS – DAAS ESG Office, further
steps in the appeal process will be provided to the applicant in writing.
The appeal must be in writing on your organization’s letter head, signed by the contract signing authority and
addressed to Mr. Joseph Breen:
Mr. Joseph M. Breen, MS
Section Chief
Division of Aging and Adult Services, Planning, ESG and Service Support Section
NC Department of Health and Human Services
693 Palmer Drive-Taylor Building
2101 Mail Service Center
Raleigh, NC 27699-2101
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Environmental Review Form
Pursuant to 24 CFR Part 58.34(a) and 58.35(b)
COMPLETE ONLY THE HIGHLIGHTED
Project Information
Grant Recipient: Orange County
Funded Activity X RRH ☐SO ☐ES ☐PRV ☐HMIS
Responsible Entity: NC DHHS – DAAS ESG Office
State/Local Identifier (LPA)
Preparer Name & Title: Rachel Waltz, Homeless Programs Manager
Certifying Officer Name and Title: Lisa Worth, ESG Homeless Programs Coordinator
Consultant (if applicable): N/A
Physical Address of Funded Activity: Community based service is to be provided in Participants’
homes or other community locations to meet the needs of the Participants.
*If multiple locations, please list all below.
Office locations include: 2501 Homestead Rd, Chapel Hill, NC 27516 and 300 W. Tryon Rd,
Hillsborough, NC 27278
Description of the Proposed Project: The proposed project will provide evidence based Rapid Re-
housing components to households currently experiencing homelessness and in accordance with 24
CFR 576: rapid re-housing assistance, housing relocation and stabilization services, and rental
assistance. Referrals will be received from the CoC By Name List meetings referred to as the HOME
Committee.
If this project anticipates the use of funds or assistance from another Federal agency in addition to
HUD (if applicable list sources): N/A
Estimated Total Project Cost (HUD and non-HUD funds): $565,452
Preparer Signature: __________________________________________Date: ________
Name/Title/Organization: Rachel Waltz / Homeless Programs Manager / Orange County
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NC ESG Certification of Consistently
With Limited English Proficiency
Executive Order 13166
We the undersigned entity, hereby testify that our organization adheres to a Limited English
Proficiency protocol, in compliance with EO 13166, signed on August 11, 2000, directing all
federal agencies, including the Department of Housing and Urban Development (HUD), to
work to ensure that programs receiving federal financial assistance provide meaningful access
to LEP persons.
Name of Organization: __Orange County_______________________________________
Name of Authorized Agent _Bonnie Hammersley __________________________________
Title of Authorized Agent _County Manager ______________________________________
Signature of Authorized Agent _________________________________________________
Date
Name of Witness __Laura Jensen______________________________________________
Signature of Witness ________________________________________________________
Date
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11/22/2021
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FEDERAL CERTIFICATIONS
The undersigned states that:
a) He or she is the duly authorized representative of the Contractor named below;
b) He or she is authorized to make, and does hereby make, the following certifications on behalf of the Contractor,
as set out herein:
a. The Certification Regarding Nondiscrimination;
b. The Certification Regarding Drug-Free Workplace Requirements;
c. The Certification Regarding Environmental Tobacco Smoke;
d. The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions; and
e. The Certification Regarding Lobbying;
c) He or she has completed the Certification Regarding Drug-Free Workplace Requirements by providing the
addresses at which the contract work will be performed;
d) [Check the applicable statement]
[ ] He or she has completed the attached Disclosure Of Lobbying Activities because the Contractor has
made, or has an agreement to make, a payment to a lobbying entity for influencing or attempting to
influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress,
or an employee of a Member of Congress in connection with a covered Federal action;
OR
[X] He or she has not completed the attached Disclosure Of Lobbying Activities because the Contractor
has not made, and has no agreement to make, any payment to any lobbying entity for influencing or
attempting to influence any officer or employee of any agency, any Member of Congress, any officer or
employee of Congress, or any employee of a Member of Congress in connection with a covered Federal
action.
e) The Contractor shall require its subcontractors, if any, to make the same certifications and disclosure.
________________________________________________________County Manager_______________
Signature Title
_Bonnie Hammersley______________________________________________________January 4, 2022
Contractor Name Date
[This Certification Must be Signed by the Same Individual Who Signed the Proposal Execution Page]
I. Certification Regarding Nondiscrimination
The Contractor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include
but are not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88 -352) which prohibits discrimination on the
basis of race, color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C.
§§1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the
Rehabilitation Act of 1973, as amended (29 U.S.C. §794), which prohibits discrimin ation on the basis of handicaps;
(d) the Age Discrimination Act of 1975, as amended (42 U.S.C. §§6101-6107), which prohibits discrimination on the
basis of age; (e) the Drug Abuse Office and Treatment Act of 1972 (P.L. 92 -255), as amended, relating to
nondiscrimination on the basis of drug abuse; (f) the Comprehensive Alcohol Abuse and Alcoholism Prevention,
Treatment and Rehabilitation Act of 1970 (P.L. 91-616), as amended, relating to nondiscrimination on the basis of
alcohol abuse or alcoholism; (g) Title VIII of the Civil Rights Act of 1968 (42 U.S.C. §§3601 et seq.), as amended,
relating to nondiscrimination in the sale, rental or financing of housing; (h) the Food Stamp Act and USDA policy,
which prohibit discrimination on the basis of religion and pol itical beliefs; and (i) the requirements of any other
nondiscrimination statutes which may apply to this Agreement.
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II. Certification Regarding Drug-Free Workplace Requirements
1. The Contractor certifies that it will provide a drug-free workplace by:
a. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession or use of a controlled substance is prohibited in the Contractor’s workplace and specifying the
actions that will be taken against employees for violation of such prohibition;
b. Establishing a drug-free awareness program to inform employees about:
i. The dangers of drug abuse in the workplace;
ii. The Contractor’s policy of maintaining a drug-free workplace;
iii. Any available drug counseling, rehabilitation, and employee assistance programs; and
iv. The penalties that may be imposed upon employees for drug abuse violations occurring in the
workplace;
c. Making it a requirement that each employee be engaged in the performance of the agreement be given a
copy of the statement required by paragraph (a);
d. Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under
the agreement, the employee will:
i. Abide by the terms of the statement; and
ii. Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no
later than five days after such conviction;
e. Notifying the Department within ten days after receiving notice under subparagraph (d)(ii) from an employee
or otherwise receiving actual notice of such conviction;
f. Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(ii), with
respect to any employee who is so convicted:
i. Taking appropriate personnel action against such an employee, up to and including
termination; or
ii. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation
program approved for such purposes by a Federal, State, or local health, law enforcement, or other
appropriate agency; and
g. Making a good faith effort to continue to maintain a drug-free workplace through implementation of
paragraphs (a), (b), (c), (d), (e), and (f).
2. The sites for the performance of work done in connection with the specific agreement are listed below (list all
sites; add additional pages if necessary):
Address
Street
__300 W. Tryon St_________________________________________________________________
City, State, Zip Code ___Hillsborough, NC 27278_________________________________________
Street
___2501 Homestead Rd____________________________________________________________
City, State, Zip Code ____Chapel Hill, NC 27516_________________________________________
3. Contractor will inform the Department of any additional sites for performance of work under this agreement.
4. False certification or violation of the certification may be grounds for suspension of payment, suspension or
termination of grants, or government-wide Federal suspension or debarment. 45 C.F.R. 82.510.
III. Certification Regarding Environmental Tobacco Smoke
Public Law 103-227, Part C-Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act),
requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an
entity and used routinely or regularly for the provision of health, day care, education, or library services to children
under the age of 18, if the services are funded by Federal programs either directly or through State or local
governments, by Federal grant, contract, loan, or loan guarantee. The law does not apply to children's services
provided in private residences, facilities funded solely by Medicare or Medicaid funds, and portions of facilities used
for inpatient drug or alcohol treatment. Failure to comply with the provisions of the law may result in the imposition
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of a civil monetary penalty of up to $1,000.00 per day and/or the imposition of an administrative compliance order
on the responsible entity.
The Contractor certifies that it will comply with the requirements of the Act. The Contractor further agrees that it
will require the language of this certification be included in any subawards that contain provisions for children's
services and that all subgrantees shall certify accordingly.
IV. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions
Instructions
[The phrase "prospective lower tier participant" means the Contractor.]
1. By signing and submitting this document, the prospective lower tier participant is providing the certification set
out below.
2. The certification in this clause is a material representation of the fact upon which reliance was placed when this
transaction was entered into. If it is later determined that the prospective lower tier participant knowingly
rendered an erroneous certification, in addition to other remedies available to the Federal Government, the
department or agency with which this transaction originate may pursue available remedies, including
suspension and/or debarment.
3. The prospective lower tier participant will provide immediate written notice to the person to whom this proposal
is submitted if at any time the prospective lower tier participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction,"
"participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used
in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing
Executive Order 12549, 45 CFR Part 76. You may contact the person to whom this proposal is submitted for
assistance in obtaining a copy of those regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered
transaction be entered into, it shall not knowingly enter any lower tier covered transaction with a person w ho is
debarred, suspended, determined ineligible or voluntarily excluded from participation in this covered transaction
unless authorized by the department or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this document that it will include the clause
titled "Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion --Lower Tier
Covered Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower
tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier
covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from covered
transaction, unless it knows that the certification is erroneous. A participant may decide the method and
frequency by which it determines the eligibility of its principals. Each participant may, but is not required to,
check the Nonprocurement List.
8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order
to render in good faith the certification required by this clause. The knowledge and information of a participant
is not required to exceed that which is normally possessed by a prudent person in the ordinary course of
business dealings.
9. Except for transactions authorized in paragraph 5 of these instructions, if a participant in a covered transaction
knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or
voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal
Government, the department or agency with which thi s transaction originated may pursue available remedies,
including suspension, and/or debarment.
Certification
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1. The prospective lower tier participant certifies, by submission of this document, that neither it nor its
principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
excluded from participation in this transaction by any Federal department or agency.
2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such
prospective participant shall attach an explanation to this proposal.
V. Certification Regarding Lobbying
The Contractor certifies, to the best of his or her knowledge and belief, that:
1. No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person
for influencing or attempting to influence an officer or employee of any agency, a Member of Cong ress, an
officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of
any Federal contract, continuation, renewal, amendment, or modification of any Federal contract, grant, loan,
or cooperative agreement.
2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing
or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee
of Congress, or an employee of a Member of Congress in connection with this Federally funded contract, grant,
loan, or cooperative agreement, the undersigned shall complete and submit Standard Form SF-LLL, "Disclosure
of Lobbying Activities," in accordance with its instructions.
3. The undersigned shall require that the language of this certification be included in the award document for
subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative
agreements) who receive federal funds of $100,000.00 or more and that all subrecipients shall certify and
disclose accordingly.
4. This certification is a material representation of fact upon which reliance was placed when this transaction was
made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction
imposed by Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be
subject to a civil penalty of not less than $10,000.00 and not more than $100,000.00 for ea ch such failure.
VI. Disclosure Of Lobbying Activities
Instructions
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at
the initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31
U.S.C. section 1352. The filing of a form is required for each payment or agreement to make payment to any
lobbying entity for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with a
covered Federal action. Use the SF-LLL-A Continuation Sheet for additional information if the space on the form
is inadequate. Complete all items that apply for both the initial filing and material change report. Refer to the
implementing guidance published by the Office of Management and Budget for additional information.
1. Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence
the outcome of a covered Federal action.
2. Identify the status of the covered Federal action.
3. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to
the information previously reported, enter the year and quarter in which the change occurred. Enter the date of
the last previously submitted report by this reporting entity for this covered Federal action.
4. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if
known. Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a
prime or sub-award recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the
1st tier. Subawards include but are not limited to subcontracts, subgrants and contract awards under grants.
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5. If the organization filing the report in Item 4 checks "Subawardee", then enter the full name, ad dress, city, state
and zip code of the prime Federal recipient. Include Congressional District, if known.
6. Enter the name of the Federal agency making the award or loan commitment. Include at least one
organizational level below agency name, if known. For example, Department of Transportation, United States
Coast Guard.
7. Enter the Federal program name or description for the covered Federal action (Item 1). If known, enter the full
Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperat ive agreements, loans, and loan
commitments.
8. Enter the most appropriate Federal Identifying number available for the Federal action identified in Item 1 (e.g.,
Request for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, the contract
grant, or loan award number, the application/proposal control number assigned by the Federal agency). Include
prefixes, e.g., "RFP-DE-90-001."
9. For a covered Federal action where there has been an award or loan commitment by the Federal agenc y, enter
the Federal amount of the award/loan commitment for the prime entity identified in Item 4 or 5.
10. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity
identified in Item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a).
Enter Last Name, First Name and Middle Initial (MI).
11. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to the
lobbying entity (Item 10). Indicate whether the payment has been made (actual) or will be made (planned).
Check all boxes that apply. If this is a material change report, enter the cumulative amount of payment made
or planned to be made.
12. Check the appropriate boxes. Check all boxes that apply. If payment is made through an in -kind contribution,
specify the nature and value of the in-kind payment.
13. Check the appropriate boxes. Check all boxes that apply. If other, specify nature.
14. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected
to perform, and the date(s) of any services rendered. Include all preparatory and related activity, not ju st time
spent in actual contact with Federal officials. Identify the Federal official(s) or employee(s) contacted or the
officer(s), employee(s), or Member(s) of Congress that were contacted.
15. Check whether or not a SF-LLL-A Continuation Sheet(s) is attached.
16. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding the burden estimate or any
other aspect of this collection of information, including sugge stions for reducing this burden, to the Office of
Management and Budget, Paperwork Reduction Project (0348-0046), Washington, D. C. 20503
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Disclosure Of Lobbying Activities
(Approved by OMB 0344-0046)
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
1. Type of Federal Action:
a. contract
b. grant
c. cooperative agreement
d. loan
e. loan guarantee
f. loan insurance
2. Status of Federal Action:
a. Bid/offer/application
b. Initial Award
c. Post-Award
3. Report Type:
a. initial filing
b. material change
For Material Change Only:
Year___________ Quarter____________
Date Of Last Report:_________________
4. Name and Address of Reporting Entity:
Prime
Subawardee Tier (if known) ________________________
Congressional District (if known) _________________________
5. If Reporting Entity in No. 4 is Subawardee, Enter Name and
Address of Prime:
Congressional District (if known) ________________________
6. Federal Department/Agency:
7. Federal Program Name/Description:
CFDA Number (if applicable) ________________________
8. Federal Action Number (if known)
9. Award Amount (if known) $
10. a. Name and Address of Lobbying Entity
(if individual, last name, first name, MI):
(attach Continuation Sheet(s) SF-LLL-A, if necessary)
b. Individuals Performing Services (including address if different
from No. 10a.) (last name, first name, MI):
(attach Continuation Sheet(s) SF-LLL-A, if necessary)
11. Amount of Payment (check all that apply):
$ € actual € planned
13. Type of Payment (check all that apply):
a. retainer
b. one-time fee
c. commission
d. contingent fee
e. deferred
f. other; specify: _____________________________
12. Form of Payment (check all that apply):
a. cash
b. In-kind; specify: Nature
Value
14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or Member(s)
contacted, for Payment Indicated in Item 11(attach Continuation Sheet(s) SF-LLL-A, if necessary):
15. Continuation Sheet(s) SF-LLL-A attached: Yes No
16. Information requested through this form is authorized by
title 31 U. S. C. section 1352. This disclos ure of lobbying
activities is a material representation of fact upon which
reliance was placed by the tier above when this transaction
was made or entered into. This disclosure is required
pursuant to 31 U. S. C. 1352. This information will be
reported to the Congress semi-annually and will be
available for public inspection. Any person who fails to file
the required disclosure shall be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each
such failure.
Signature:
Print Name:
Title: ______________________________________________
Telephone No: Date:
Federal Use Only Authorized for Local Reproduction
Standard Form - LLL
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State Certifications
Contractor Certifications Required by North Carolina Law
Instructions
The person who signs this document should read the text of the statutes listed below and consult with counsel and other knowledgeable
persons before signing. The text of each North Carolina General Statutes can be found online at:
Article 2 of Chapter 64: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/ByArticle/Chapter_64/Article_2.pdf
G.S. 105-164.8(b): http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_105/GS_105 -164.8.pdf
G.S. 143-48.5: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_143/GS_143-48.5.html
G.S. 143-59.1: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143/GS_143-59.1.pdf
G.S. 143-59.2: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143/GS_143-59.2.pdf
G.S. 147-33.95(g): http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_147/GS_147-33.95.html
Certifications
(1) Pursuant to G.S. 143-48.5 and G.S. 147-33.95(g), the undersigned hereby certifies that the Contractor named below, and
the Contractor’s subcontractors, complies with the requirements of Article 2 of Chapter 64 of the NC General Statutes,
including the requirement for each employer with more than 25 employees in North Carolina to verify the work author ization
of its employees through the federal E-Verify system." E-Verify System Link: www.uscis.gov
(2) Pursuant to G.S. 143-59.1(b), the undersigned hereby certifies that the Contractor named below is not an “ineligible
Contractor” as set forth in G.S. 143-59.1(a) because:
(a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of Chapter
105 of the General Statutes on its sales delivered to North Carolina when the sales met one or more of the conditions
of G.S. 105-164.8(b); and
(b) [check one of the following boxes]
☒ Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a “tax haven country” as set
forth in G.S. 143-59.1(c)(2) after December 31, 2001; or
☐ The Contractor or one of its affiliates has incorporated or reincorporated in a “tax haven country” as set forth in G.S.
143-59.1(c)(2) after December 31, 2001 but the United States is not the principal market for the public trading of
the stock of the corporation incorporated in the tax haven country.
(3) Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor’s officers, directors, or owners (if
the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter 78A of the General Statutes
or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years immediately prior to the date of the bid
solicitation.
(4) The undersigned hereby certifies further that:
a) He or she is a duly authorized representative of the Contractor named below;
b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the Contractor;
and
c) He or she understands that any person who knowingly submits a false certification in response to the requirements
of G.S. 143-59.1and -59.2 shall be guilty of a Class I felony.
The witness should be present when the Contractor’s Authorized Agent signs this certification and should sign and
date this document immediately thereafter.
Orange County
Contractor’s Name
1/4/22
Signature of Contractor’s Authorized Agent Date
Bonnie Hammersley County Manager
Printed Name of Contractor’s Authorized Agent Title
1/4/22
Signature of Witness Date
Laura Jensen County Clerk
Printed Name of Witness Title
The witness should be present when the Contractor’s Authorized Agent signs this certification and should sign and date this document immediately thereafter.
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Revised 07/20
ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Party/Vendor Name: OCHCD Party/Vendor Contact Person: Corey Root Contact Phone: 919-245-2492
Party/Vendor Address: 300 West Tryon St City Hillsborough State: NC Zip: 27278 Department: OCHCD
Amount: $40,526 Purpose: Rapid Rehousing service Budget Code(s): 32470605 442235 71084 Vendor # N/A
(N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New
Renewal Amendment Effective Date 11/18/2021 Approved by Board Yes No Agenda Date:
This agreement is approved as to technical form and content and I as Department Director affirmatively state work on
this project has not been initiated prior to execution of the agreement:
Department Director’s Signature ________________________________________ Date: ________
Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that
was addressed:
Information Technologies
(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer___________________________________ Date: ________
Risk Management
This agreement is approved for sufficiency of insurance standards, specifications, and requirements:
Office of the Risk Management Officer___________________________________ Date: _________
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer ____________________________________ Date: _________
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney __________________________________________Date: ________
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board __________________________________________Date:_________
DocuSign Envelope ID: A80A68F0-12D3-42DA-80C7-45C66A2BB398
11/18/2021
11/18/2021
11/21/2021
11/21/2021