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HomeMy WebLinkAboutAgenda 04-26-22; 8-i - Approval of Contract Accepting Housing Staff Grant Funding from the Foundation for Health Leadership and Innovation 1 ORANGE COUNTY BOARD OF COMMISSIONERS ACTION AGENDA ITEM ABSTRACT Meeting Date: April 26, 2022 Action Agenda Item No. 8-i SUBJECT: Approval of Contract Accepting Housing Staff Grant Funding from the Foundation for Health Leadership and Innovation DEPARTMENT: Housing and Community Development ATTACHMENT(S): INFORMATION CONTACT: 1. FNLI Contract Corey Root, 919-245-2492 PURPOSE: To approve a contract accepting a grant from the Foundation for Health Leadership and Innovation (FHLI) for two new positions in the Housing Department — a Team Lead for the Housing Helpline and partial funding for a Housing Locator position (to be paired with ARPA funding authorized in FY 2021-22 to create a 1.0 full time equivalent (FTE) position). BACKGROUND: The Foundation for Health Leadership and Innovation awarded $99,988 to Orange County on March 31, 2022 as part of the NCCARE360 Community Organization Health Equity Grant competition. FHLI awarded 15 community organizations in 10 counties to support the growth of NCCARE360. NCCARE360 is a statewide online referral network connecting health care and human services. Service providers can electronically refer clients to community resources via NCCARE360, and also track the status of those referrals, give feedback, and follow up. Orange County was awarded funding to support two staff positions: 1.0 FTE Funding for Coordinated Entry Team Lead This position provides leadership and guidance to the Housing Helpline team that directs customer service to people in housing crisis, assisting people as they navigate housing resources for homelessness prevention, emergency response involving shelter, and permanent housing. The staff member in this position will: • Provide direct supervision for Housing Helpline team members, including conducting weekly individual check-ins and weekly team meetings • Serve as point of contact for referrals coming from and referrals made via NCCARE360 • Provide technical assistance to community agencies seeking to use NCCARE360 for coordinated entry referrals 2 • Conduct analysis of NCCARE360 referrals received by Housing Helpline staff, and made by Housing Helpline staff and provide feedback to OCPEH Homeless Programs Manager and OCPEH Homeless Programs Coordinator as needed • Provide direct client support as needed, including: Provide information to clients and assist them in housing, problem-solving, relevant program processes, and makes referrals to human service resources via NCCARE360; • Perform walk-in and telephone assessments, and provide trauma-informed care to persons presenting for housing coordinated entry; • Interview clients to gather information and lead structured conversations; • Maintain client documentation and electronic records in accordance with program requirements and NCCARE360 guidelines, policies and accepted professional standards in order to provide accountability for the expenditure of local, state and federal funds; • Provide direct customer service to service providers, participants, and the general public responding to inquiries, requests and follow up; • Prepare and present information regarding NCCARE360 coordinated entry to human service agencies, civic and community groups, and individual citizens as requested; • Contribute to the HOME Committee and Coordinated Entry Planning Group and/or other assigned team(s) by actively participating in team meetings and special projects, processing improvements, collaborating with and supporting all team members, and following through on initiatives and assignments, as directed; • Interact and communicate with various groups and individuals such as County staff, clients, service providers, community audiences and the general public; • Perform various administrative tasks including preparing reports and correspondence, preparing meeting materials, and creating reports; • Use computer applications or other automated systems such as NCCARE360, spreadsheets, word processing, calendar, e-mail and database software in performing work assignments; and • Attend ongoing training from NCCARE360, HUD, and technical assistance providers .5 FTE Funding for Housing Locator (to be combined with ARPA funding approved in FY 2021- 22 to create 1.0 FTE) This position provides housing search assistance to people exiting homelessness and people at risk of homelessness. The staff member in this position will: • Work with the Housing Access Coordinator to update and maintain the Orange County Affordable Housing list • Accept referrals via NCCARE360, and make referrals via NCCARE360 as needed • Work with clients to identify and overcome barriers to housing entry • Provide people in housing search with tailored lists of housing options • Accompany people on housing searches, as needed • Assist people with accessing funding for application fees, as needed • Work with the Housing Access Coordinator to develop and maintain relationships with landlords and property managers in Orange County FINANCIAL IMPACT: There is no financial impact to the County with approving the contract accepting these grant funds, but a future financial impact could occur should the County want to continue these positions after the grant funding ends in May 2023. 3 SOCIAL JUSTICE IMPACT: The following Orange County Social Justice Goals are applicable to this item: • GOAL: FOSTER A COMMUNITY CULTURE THAT REJECTS OPPRESSION AND INEQUITY The fair treatment and meaningful involvement of all people regardless of race or color; religious or philosophical beliefs; sex, gender or sexual orientation; national origin or ethnic background; age; military service; disability; and familial, residential or economic status. • GOAL: ENSURE ECONOMIC SELF-SUFFICIENCY The creation and preservation of infrastructure, policies, programs and funding necessary for residents to provide shelter, food, clothing and medical care for themselves and their dependents. • GOAL: CREATE A SAFE COMMUNITY The reduction of risks from vehicle/traffic accidents, childhood and senior injuries, gang activity, substance abuse and domestic violence. ENVIRONMENTAL IMPACT: There are no Orange County Environmental Responsibility Goal impacts applicable to this item. RECOMMENDATION(S): The Manager recommends that the Board approve and authorize the County Manager to sign the FHLI grant contract. 4 dA FOUNDATION FOR HEALTH � x I_LADF�S1--1IP I�INC�VArIO MOVING PEOPLE ANO IOF_AS INTO ACTION Bonnie Hammersley,County Manager Rachel Waltz,Homeless Programs Manager Orange County Government i Orange County Partnership to End Homelessness 300 W.Tryon Street Hillsborough,North Carolina 27278 RE: NCCARE360 Community Organization Health Equity Grant Award Notification March 31, 2022 Congratulations!We are pleasedto informyou that yourapplication forthe NCCARE360 Community Organization Health Equity Grant has been selected in the amountof$99,988 to support your project at the Orange County Partnershipto End Homelessness.You will receive more detailed information regarding reporting requirements,timelines,terms and conditions as we move forward in drafting your contract. All awardees are required to attend the two-hourgrant orientation. Please note the date below for your grant award orientation and make every effortto attend. NCCARE360 Community Organization Grant Awardee Orientation—4/14/22 at 2 PM Thursday,April 14, 2022 2:00 PM-4:00 PM Eastern Time (US and Canada) https://us02web.zoom.us/j/85839755231?pwd=VE9nS1ZKNWFtYXp4Y29TaIIGTHpSdzO9 Meeting I D:858 3975 5231 Passcode:215536 Should you have anyquestions aboutthis matter,please feelfree to contact LaQuana Palmer,Program Director of NCCARE360 at RFP@foundationh!i.org. We wish you continued success. Sincerely, j Kelly Calabria, Presidentand CEO, Foundation for Health Leadership and Innovation i i 2401 Weston Parkway Tel:919.821.0485 Suite 203 Fax:919.694.1047 Cary,North Carolina 27513 www.foundationlili.org 5 6 NCCARE360 HEALTH EQUITY GRANT AGREEMENT THIS GRANT AGREEMENT ("Agreement")is made the 31 day of MARCH,20_22_ ("Effective Date"), between The Foundation for Health Leadership and Innovation("FHLI") and ORANGE COUNTY GOVERNMENT("Grantee"). 3 1. Grant. FHLI shall make a grant to Grantee (the "Grant Funds") in the amount of $99,988.00, on the schedule, and for the purpose of engaging in the activities described on Exhibit A attached to this Agreement (the "Grant"). The Grant Funds are intended to support usage and benefits from NCCARE360, and Grantee agrees to cooperate and coordinate as necessary with FHLI,the NC Department of Health and Human Services, Unite Us, NC 2-1-1, and other program partners in carrying out the activities facilitated through the Grant Funds. This is a grant and not a contract based on fees for services. All Grant Funds that have not been expended at the conclusion of the Term shall revert to FHLI. 2. Incorporation of RFA Response. FHLI is making the Grant to Grantee in reliance upon the representations in Grantee's Response to the NCCARE 360 Community Organizations and Network Support Agencies Health Equity Grants Request for Applications (the"RFA Response"). The Grant is conditioned upon Grantee's compliance with all terms and conditions set forth in the RFA Response, which is incorporated herein by reference. 3. Term. The Grant period is set forth in Exhibit A. All Grant funds shall be expended solely to conduct the activities described in Exhibit A and must follow the budget and timeline set forth in Exhibit B. 4. Termination. FHLI may terminate this Agreement, and — at its option — suspend distribution of further funds,upon the occurrence of any of the following: (a) Grantee fails to comply with any terms or conditions in this Agreement, the RFA Response, or any of the other terms and conditions attached to or referenced or incorporated in this Agreement, and fails to cure the issue within ten (10) days following receipt of written notice of the violation from FHLI; (b) Grantee terminates or suspends its business; becomes subject to any banitruptcy or insolvency proceeding under Federal or state statute;becomes insolvent or subject to direct control by a trustee, receiver or similar authority; or has wound up or liquidated,voluntarily or otherwise, its business; (c) Funds designated for the purpose of malting the Grant are no longer available. 5. Monthly Reports. On or before the 5t1'day of each month during the Term, Grantee must submit to FHLI, via email addressed to LaQuana.Palmer(&,,foundationhli.org, a progress report documenting activities using Grant Funds for the prior month in the format set forth in Exhibit A attached hereto; 1 i 7 6. Budget Reports and Invoices. On or before the 5th day of each month during the Term, Grantee must submit to FHLI, via email addressed.to Kitrl.BametLa)foundationlili.ol•C", a budgetreport and invoices to FHLI documenting spending for the prior month in the format set forth in Exhibit B attached hereto. 7. Final Report. On or before thirty (30) days following the end of the Term, Grantee shall provide a final report summarizing all activities and expenditures using the Grant Funds in the format set forth in Exhibit A and B attached hereto. 8. Copyright. FHLI shall be the owner,and Grantee hereby irrevocably and unconditionally assigns to FHLI,all right,title and interest in and to the copyright and all other intellectual property rights in and to the reports and other deliverables provided by or on behalf of Grantee to FHLI pursuant to this Agreement. 9. Compliance with Law. Grantee agrees to comply with all national, federal, state, provincial and local laws,rules, regulations, treaties, ordinances and standards applicable to the Grant,the use of the Grant funds and Grantee's activities. 10. Restrictions on Use of Funds. Grantee may not use the Grant Funds: (a) To conduct research; (b) To provide clinical care except as allowed by law; (c) Unless expressly itemized and provided for in the budget,to purchase furniture or equipment (except desktop,laptop, or tablet computing devices); (d) For reimbursement of pre-award costs; (e) Other than for normal and recognized executive-legislative relationships: (i) for publicity or propaganda purposes, for the preparation, distribution, or use of any material designed to support or defeat the enactment of legislation before any legislative body,or (ii) for the salary or expenses of any grant or contract recipient, or agent acting for such recipient, related to any activity designed to influence the enactment of legislation, appropriations, regulation, administrative action, or Executive order proposed or pending before any legislative body. It. Compliance with Additional Terms and Conditions. Grantee must comply with all grant award requirements set forth at https://www.cdc.go`,/grants/documentsiGeneral- Ter-ms-and-Conditions-Non-Research-Awards.pdf and APPENDIX 1,which are incorporated by reference. 12. Trademarks. Grantee may use promotional or communication materials from FHLI, Unite Us, and/or other program partners and it may refer to NCCARE360 and the 2 f i 8 7: organization name, seivice marks or trademarks of FHLI,Unite Us and other NCCARE360 partners (the "Program Marks") in connection with the Grant only in accordance with written instructions provided by or on behalf of FHLI from time to time. Grantee may publicly distribute newly created promotional or communication materials referring to j NCCARE360 or the Program Marks developed by or on behalf of Grantee only after providing such materials to FHLI for review and receiving FHLI's prior written consent. i 13. Conflicts of Interest. The Grantee shall disclose any relationship to any business or associate to whom the organization is currently doing business that creates or may give the appearance of a conflict of interest related to the Grant provided to Grantee. 14. Records and Audit. Grantee agrees to keep accurate books of accounts and records of its activities in connection with the Grant funds. In addition,Grantee shall maintain all books, accounts and records required by FHLI. Grantee shall retain all such books, accounts and records for a period of four (4) years after the expiration or earlier termination of this Agreement. FHLI may upon reasonable notice review the books, accounts and records of Grantee regarding the Grant funds. Grantee will cooperate fully with any such inspection or audit and will provide all records requested by FHLI. In the event the audit demonstrates the Grantee has not used all or a portion of the funds in accordance with the terms of this Agreement, FHLI shall within thirty (30) days after written demand from FHLI return all excess funds to FHLI, and FHLI may cease to disburse any further funds under the Agreement. 15. Indemnification by Grantee. Grantee agrees to indemnify and hold FHLI and its officials, officers, directors,, donors, agents and employees, harmless of any from any claim, demand, liability, loss, judgment, award, and expenses (including reasonable attorneys fees) of whatever type and nature arising, directly or indirectly, from (a) Grantee's breach of this Agreement; (b) Grantee's failure to comply with applicable law; (c) Grantee's use or misuse of Grant Funds; or (d) Grantees negligent or willful acts or omissions relating to the Grant or this Agreement that result in injury or damage to any thud party. 16. Assignment. The rights and obligations of Grantee under this Agreement may not be assigned by Grantee, without the prior written consent of FHLI, which consent may be withheld for any reason. Subject to the restriction on assignment to another party, the provisions of this Agreement shall be binding upon and inure to the benefit of the parties to this Agreement and their successors and assigns. 17. Modification. The parties to this Agreement may amend this Agreement only in writing duly executed by both parties to this Agreement. 18. Rij4hts and Remedies. The rights and remedies granted by this Agreement shalt not limit any others available to a party to this Agreement, and no delay or partial exercise of any right or remedy shall operate to waive or prejudice the ability to exercise those rights or remedies later. i' 3 9 19. Severability. If any part of this Agreement shall be determined to be unenforceable, then such determination shall not affect any other part of this Agreement, all of which other parts shall remain in full force and effect. 20. Survivorship. Where any provision contained in this Agreement evidences the intent of the parties that such provision should survive the distribution of the Grant funds and the expiration or termination of this Agreement, the provision shall survive those events (e.g. Section 14 Indemnification by Grantee). 21. Governing Law. This Agreement shall be construed and enforced in accordance with the laws of the State of North Carolina, without regard to its principles of conflicts of law. 22. Entire Agreement. This Agreement shall constitute the entire understanding between the parties, superseding any and all previous understandings,oral or written,pertaining to the subject matter contained herein. The exhibits attached to this Agreement and the terms and conditions incorporated by reference shall apply as if set out fully in this Agreement. IN WITNESS WHEREOF,the parties hereto have caused this Grant Agreement to be signed by duly authorized representatives, all to be effective the day and year first above written. Foundation for Health Innovation Grantee and Leadership By: By: Print Nam Kelly Calabria Print Name: Print Title: President/CEO Print Title: Date Signed: f-1 h L.) Date Signed: 4 i i, 10 EXHIBIT A.NCCARE360 Community Organization Health Equity Grant Project Plan GRANT PERIOD:March 31,2022—May 21,2023 i PROJECT TITLE:IncorporatingNCCARE 360 into Coordinated Entry 3 i 1# PROJECT SUMMARY: Orange County Housing Helpline will increase community members access to 1 housing resources by accepting and placing referrals in NC CARE 3 60.Rapid access to the right housing resource has been shown to improve health outcomes and reduce costs to multiple systems of care ORGANIZATION PROFILE Name Orange County Address(Headquarters) 300 West Ti yon St,Hillsborough,NC 2 727 8 Main Telephone Number 919-245-2490 Website http://Nvww.orangecountync.gov/ r r Name Address Main Telephone Number Website Name Bonnie Hammersley Title County Manager Address 300 West Tryon St,Hillsborough,NC 27278 Telephone Number 919-245-2300 Email Address bhammetsleyAorangecountync.gov 5 11 Main Contact for Grant< Name Rachel Waltz Title Homeless Programs Manager Address 300 West Tryon St,Hillsborough,NC 27278 Telephone Number 919-245-2496 Email Address rwaltz(&orangecountync.gov PERFORMANCE REQUIREMENTS Grant Activities Grantees will strengthen the NCCARE360 network of community organizations that can respond to referrals and provide community services by implementing activities to reduce barriers to onboarding onto NCCARE360 and/orbetter sustain additional referrals or needs as identified in the grantee's project description. To grow the NCCARE360 network(adding additional organizations) and/or to grow use of NCCARE360 among organizations already onboarded, [GRANTEE ORGANIZATION NAME] has selected to complete the following activities: Required Activities ® Onboarding onto or increasing use of NCCARE360 in organization programs and workflows. Costs could relate to administrative, staffing,and/or other relevant costs pertaining to NCCARE360 implementation, workflow planning, staff training, and quality improvement. Optional Activities N Providing additional direct services stemming from accepting additional referrals through NCCARE360(e.g.,funding for additional food boxes for a food pantry or case manager time for a housing provider due to increased referrals to the organization); and/or ® Engagement/education of staff and/or clients served by the organization on NCCARE360; and/or ❑ Expand and address language access for limited English proficiency and/or other communication needs;and/or ❑ Organization staff to serve as an NCCARE360 champion to share information about NCCARE360 to partner organizations in community; and/or 6 a fi 12 a i i I ❑ Supporting organization financial systems and/or financial staff to better support additional funding sources including from health care partners; and/or ❑ Administrative, staffing,and other costs related to partnering and working with health care organizations and/or other partners on funding opportunities; and/or ❑ Providing professional development on equity that builds understanding of and competencies to advance health equity strategies and activities; and/or ❑ Addressing other barriers to utilization and onboarding onto NCCARE360 identified by your organization. 6 SERVICE AREA i The counties included for this project are: ❑Durham 7 ❑ Chatham i ❑ Lee ❑Harnett ❑ Wake ® Orange ❑ Johnston ❑ Granville ❑ Vance r ❑Franklin i i i I 1 PROJECT DESCRIPTION 7 13 13 rtrf&sh to End Homelessness CBO Position descriptions Coordinated Entry Team lead 40 hours/week(full time) Time-limited position-15 months This position provides leadership and guidance to the Housing Helpline team that directs customer service to people in housing crisis,assisting people as they navigate housing resources for homelessness prevention,emergency response involving shelter,and permanent housing.The staff member in this position will: • Provide direct supervision for Housing Helpline team members,including conducting weekly individual check-ins and weekly team meetings • Serve as point of contact for referrals corning from and referrals made via NCCARE360 • Provide technical assistance to community agencies seeking to use NCCARE360 for coordinated entry referrals • Conduct analysis of NCCARE360 referrals received by Housing Helpllne staff,and made by Housing Helpline staff and provide feedback to OCPEH Homeless Programs Manager and OCPEH Homeless Programs Coordinator as needed • Provide direct client support as needed,including: o Provide information to clients and assist them in housing,problem-solving,relevant program processes,and makes referrals to human service resources via NCCARE360; o Perform walk-in and telephone assessments,and provide trauma-informed care to persons presenting for housing coordinated entry; o Interview clients to gather information and lead structured conversations; o Maintain client documentation and electronic records in accordance with program requirements and NCCARE360 guidelines,policies and accepted professional standards in order to provide accountability for the expenditure of local,state and federal funds; c Provide direct customer service to service providers,participants,and the general public responding to inquiries,requests and follow up; o Prepare and present information regarding NCCARE360 coordinated entry to human service agencies,civic and community groups,and individual citizens as requested, c Contribute to the HOME Committee and Coordinated Entry Planning Group and/or other assigned team(s)by actively participating in team meetings and special projects, processing improvements,collaborating with and supporting all team members,and following through on initiatives and assignments,as directed; c Interact and communicate with various groups and individuals such as county staff, clients,service providers,community audiences and the general public; o Perform various administrative tasks including preparing reports and correspondence, preparing meeting materials,and creating reports; o Use computer applications or other automated systems such as NCCARE360, spreadsheets,word processing,calendar,e-mail and database software in performing work assignments;and • Attend ongoing training from NCCARE360,HUD,and technical assistance providers 300 West Tryon Street Phone:919-745-2496 PO Box 8181 Fax:919-944-8496 Hillsborough,NC 27278 www.ocpehnc.com g 14 Housing Locator 20 hours/week(part time) Time-limited position-15 months This position provides housing search assistance to people exiting homelessness and people at risk of homelessness.The staff member in this position will: • Work with the Housing Access Coordinator to update and maintain the Orange County Affordable Housing list • Accept referrals via NCCARE360,and make referrals via NCCARE360 as needed • Work with clients to Identify and overcome barriers to housing entry • Provide people in housing search with tailored lists of housing options • Accompany people on housing searches,as needed • Assist people with accessing funding for application fees,as needed • Work with the Housing Access Coordinator to develop and maintain relationships with landlords and property managers in Orange County 15 P rtliership tb u; End Homelessness For each Project Activity selected above,please provide a description of(1)why your organization selected the activity;(2)what your organization plans to do to meet goals of activity and horns your organization will use grant funding to accomplish this activity. Make sure to tie each description to the budget narrative to make it as clear as possible the funding needed to achieve each project component. REQUIRED ACTIVITY(Organizations must select the required activity) 1. M Onbaarding-onto or increasing use of NCCARE360 in organization programs and workflows. Costs could relate to administrative,staffing,and/or other relevant costs pertaining to NCCARE360 implementation,workflow planning,staff training,and quality improvement. The Orange County Housing Helpline provides community wide assistance to people experiencing housing stressors including homelessness.The Housing helpline operates as the Coordinated Entry access point in the Orange County Continuum of Care and includes assessment,prioritization,and referral to community resources including the Shelter Referral List,HUD funded programs like Homelessness Prevention,Rapid Re-housing,Permanent Supportive Housing,and other permanent housing programs like Housing Choice Vouchers and Emergency Housing Vouchers.The Housing Helpline currently receives referrals from community members and service providers via telephone and email answered Monday—Friday; 10am-4pm and walk-in access on Tuesdays and Thursdays from 8:30am—4pm.Orange County Is requesting funding for Coordinated Entry Team Lead who will provide staff training and workflow planning to incorporate regular referral receipt and placement with NCCARE 360.This position will lead change management and implementation of this additional referral source. They will also provide a champion on the Housing Helpline team who will also be the point of access for community service providers. OPTIONAL ACTIVITIES(Organizations may select one(1)or more additional optional activities) 2. 0 Providing additional direct services stemming from accepting additional referrals through NCCARE360(e.g.,funding for additional food boxes for a food pantry or case manager time for a housing provider due to increased referrals to the organization);and/or Orange County Coordinated Entry provides information about affordable housing opportunities to Individuals and organizations and routinely receives requests for additional assistance. Orange County anticipates an increase in referrals through incorporation of NCARE360 and an increase in households requiring housing relocation.Orange County is requesting funding for a Housing Locator to reduce the number of households entering the homeless service system and reduce the length of time homeless for households experiencing homelessness. 3. ❑ Engagement/education of staff and/or clients served by the organization on NCCARE360; and/or 300 West Tryon Street Phone:919-245-2496 PO Box 8181 Fax:919-944-8496 Hillsborough,NC 22228 www.acpehnc.com 10 16 Coordinated Entry Team Lead will provide training to CE Staff on NCCARE60.They will routinely solicit feedback from staff and clients served through NCCARE360 to identify areas for process Improvements,gaps In service offerings,etc. 4, 0 Expand and address language access for limited English proficiency and/or other communication needs;andlor S. 0 Organization staff to serve as an NCCARE360 champion to share information about NCCARE360 to partner organizations In community; 6. 0 Supporting organization financial systems and/or financial staff to better support additional funding sources including from health care partners;and/or 7. 0 Administrative,staffing,and other costs related to partnering and working with health care organizations and/or,other partners an funding opportunities;and/or 8, 0 Providing professional development on equity that builds understanding of and competencies to advance health equity strategies and activities;and/or 9. 0 Addressing other barriers to utilization and onboarding onto NCCARE360 identified by your organization. Project Timeline 17 Parthershir End Homelessness FHLI Community Organization timeline March 2022 • Award notification • Contracting Apr 2022 • Positions posting—Coordinated Entry Team Lead,Housing Locator • Interview May 2022 • Onboard staff—CE Team Lead,Housing Locator • Complete Agency registration In NCCARE360 • Crosstrain CE staff • Housing Helpline begins to receive referrals via NCCARE360 June 2022 • CE Team Lead begins data collection and monitoring on NCCARE360 use • Housing Locator builds caseload with dedicated referral from Coordinated Entry • CE Team Lead begins outreach to service provider partners within the Continuum of Care July 2022 • Housing Locator builds caseload with dedicated referral from Coordinated Entry • Housing Locator collects referral,volume and outcome data • CE Team Lead continues to receive and place referrals in NCCARE360 • CE Team Lead prepares presentations to existing service provider partners • CE Team Lead provides monthly report to Homeless Program Manager and Homeless Program Coordinator with volume,source and outcome of NCCARE360 referrals August 2022 • Housing Locator builds caseload with dedicated referral from Coordinated Entry • Housing Locator collects referral,volume and outcome data • CE Team Lead continues to receive and place referrals in NCCARE360 • CE Team Lead presents to existing service provider partners • CE Team Lead provides monthly report to Homeless Program Manager and Homeless Program Coordinator with volume,source and outcome of NCCARE360 referrals September 2022 • Housing Locator builds caseload with dedicated referral from Coordinated Entry • Housing Locator collects referral,volume and outcome data • CE Team Lead continues to receive and place referrals in NCCARE360 • CE Team Lead explores potential service provider partners 300 West Tryon Street Phone:919-245-2496 PO Box 8181 Fax:919-944-8496 Hillsborough,NC 27278 www.ocpehnc.com REPORTING REQUIREMENTS FOR COMMUNITY ORGANIZATIONS 12 f 18 On or before the 5th day of each month during the Tern, Grantee must submit to FHLI,via email addressed to LaQuana.Palmer(a,,foundationlrli.org, a progress report documenting activities using Grant Funds for the prior month. The following information will be collected and submitted using an electronic survey link provided FHLI: • Domain of Services Provided(all that apply) l a 1 • Onboarded onto NCCARE360 as of report (Y/N) • Number of Licensed Users • Number of Referrals Received before grant award(if applicable) • Number of Referrals Accepted before grant award(if applicable) • Number of Referrals Sent before grant award (if applicable) • Number of Referrals Received month over month after grant award i • Number of Referrals Accepted month over month after grant award • Number of Referrals Sent month over month after grant award • Number of Cases before grant award(if applicable) • Number of Cases month over month after grant award • Number of Cases Resolved before grant award (if applicable) • Number of Cases Resolved month over month after grant award • Narrative of successes/challenges for project implementation Final Report On or before thirty(30) days following the end of the Tenn, Grantee shall provide a final report summarizing all activities and expenditures using the Grant Funds. The following information will be submitted using an electronic survey link provided by FHLI: • Final list of Domain of Services Provided (all that apply) 13 19 • Onboarded onto NCCARE360 as of report (Y/N) • Total Number of Licensed Users • Total Number of Referrals Received before grant award (if applicable) • Total Number of Referrals Accepted before grant award (if applicable) • Total Number of Referrals Sent before grant award (if applicable) • Total Number of Referrals Received month over month after grant award • Total Number of Referrals Accepted month over month after grant award • Total Number of Referrals Sent month over month after grant award • Total Number of Cases before grant award (if applicable) • Total Number of Cases month over month after grant award • Total Number of Cases Resolved before grant award(if applicable) • Total Number of Cases Resolved month over month after grant award • Final narrative of successes/challenges for project implementation Submit the final budget report and final invoices to FHLI documenting spending for the prior month in the format set forth in Exhibit B. 14 20 EXHIBIT B.NCCARE360 Community Organization Health Equity Grant Financial Status Report GRANT PERIOD:March 31,2022 —May 21,2023 On or before thirty(30) days following the end of the Term, Grantee shall provide a final report summarizing all activities and expenditures using the Grant Funds in the format set forth in Exhibit B. fOUNCATION FOR.HEALTH LEADERSHIP&INNWATION RRANCIAL STATUS REPORT;FS 'I r2mi ion gun y rar, ZYT6-faTADdu'ffRi---ues—Wr sRe _` 2)AnEnc o Nei -d b�iNis reggest: Ctntaa Paacn: g4,212k:-- 7702411122 4)tzrraw E Fi Orart Pa-nod: 1114,2022-6,VP202S A. 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Tice: e: 15 21 Request for Taxpayer Give Form to the Form W 9 (Rev.October 2018) Identification Number and Certification requester.Do not Department of the Treasury send to the IRS. Internal Revenue Service Op-Go to www.irs.gov/FormW9 for instructions and the latest information. a 1 Name(as shown on your income tax return).Name is required on this line;do not leave this line blank, 2 Business name/disregarded entity name,if different from above m 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1.Check only one of the 4 Exemptions codes apply only to � p Y P ( PP Y Y following seven boxes. certain entities,not individuals;see Ca CL instructions on page 3): o ElIndividual/sole proprietor or ElC Corporation ElS Corporation ElPartnership ❑ Trust/estate M single-member LLC Exempt payee code(if any) ❑ Limited liability company.Enter the tax classification(C=C corporation,S=S corporation,P=Partnership)t► o Note:Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting N LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is code if an a another LLC that is not disregarded from the owner for U.S.federal tax purposes.Otherwise,a single-member LLC that ( Y) is disregarded from the owner should check the appropriate box for the tax classification of its owner. y E] Other(see instructions)10- (Applies to accounts mafntalned outside the U.S) CL 5 Address(number,street,and apt.or suite no.)See instructions. Requester's name and address(optional) M a� M 6 City,state,and ZIP code 7 List account number(s)here(optional) 0:MIN Taxpayer Identification Number(TIN) Enter your TIN in the appropriate box.The TIN provided must match the name given on line 1 to avoid social security number backup withholding.For individuals,this is generally your social security number(SSN).However,for a resident alien,sole proprietor,or disregarded entity,see the instructions for Part 1,later.For other —m _ entities,it is your employer identification number(EIN).If you do not have a number,see How to get a TIN, later. or Note: If the account is in more than one name,see the instructions for line 1.Also see What Name and Employer identification number Number To Give the Requester for guidelines on whose number to enter. Certification Under penalties of perjury,I certify that: 1.The number shown on this form is my correct taxpayer identification number(or I am waiting for a number to be issued to me);and 2.1 am not subject to backup withholding because:(a)I am exempt from backup withholding,or(b)I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer subject to backup withholding;and 3.1 am a U.S.citizen or other U.S.person(defined below);and 4.The FATCA code(s)entered on this form(if any)indicating that I am exempt from FATCA reporting is correct. Certification instructions.You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.For real estate transactions,item 2 does not apply.For mortgage interest paid, acquisition or abandonment of secured property,cancellation of debt,contributions to an individual retirement arrangement(IRA),and generally,payments other than interest and dividends,you are not required to sign the certification,but you must provide your correct TIN.See the instructions for Part II,later. Sign Signature of Here U.S.person► Date 0- •Form 1099-DIV(dividends,including those from stocks or mutual General Instructions funds) Section references are to the Internal Revenue Code unless otherwise o Form 1099-MISC(various types of income,prizes,awards,or gross noted. proceeds) Future developments.For the latest information about developments o Form 1099-B(stock or mutual fund sales and certain other related to Form W-9 and its instructions,such as legislation enacted transactions by brokers) after they were published,go to www.irs.gov/F6rmW9. •Form 1099-S(proceeds from real estate transactions) Purpose of Form •Form 1099-K(merchant card and third party network transactions) An individual or entity(Form W-9 requester)who is required to file an •Form 1098(home mortgage interest),1098-E(student loan interest), information return with the IRS must obtain your correct taxpayer 1098-T(tuition) identification number(TIN)which may be your social security number •Form 1099-C(canceled debt) (SSN),individual taxpayer identification number(ITIN),adoption .Form 1099-A(acquisition or abandonment of secured property) taxpayer identification number(ATIN),or employer identification number (EIN),to report on an information return the amount paid to you,or other Use Form W-9 only if you are a U.S,person(including a resident amount reportable on an information return.Examples of information alien),to provide your correct TIN. returns include,but are not limited to,the following. If you do not return Form W-9 to the requester with a TIN,you might •Form 1099-INT(interest earned or paid) be subject to backup withholding.See What is backup withholding, later. Cat.No.10231X Form W-9(Rev.10-2018) 22 Form W-9(Rev.10-2018) Page 2 By signing the filled-out form,you: Example.Article 20 of the U.S.-China income tax treaty allows an 1.Certify that the TIN you are giving is correct(or you are waiting for a exemption from tax for scholarship income received by a Chinese number to be issued), student temporarily present in the United States.Under U.S.law,this student will become a resident alien for tax purposes if his or her stay in 2.Certify that you are not subject to backup withholding,or the United States exceeds 5 calendar years.However,paragraph 2 of 3.Claim exemption from backup withholding if you are a U.S.exempt the first Protocol to the U.S.-China treaty(dated April 30,1984)allows payee.If applicable,you are also certifying that as a U.S.person,your the provisions of Article 20 to continue to apply even after the Chinese allocable share of any partnership income from a U.S.trade or business student becomes a resident alien of the United States.A Chinese is not subject to the withholding tax on foreign partners'share of student who qualifies for this exception(under paragraph 2 of the first effectively connected income,and protocol)and is relying on this exception to claim an exemption from tax 4.Certify that FATCA code(s)entered on this form(if any)indicating on his or her scholarship or fellowship income would attach to Form that you are exempt from the FATCA reporting,is correct.See What is W-9 a statement that includes the information described above to FATCA reporting, later,for further information. support that exemption. Note:If you are a U.S.person and a requester gives you a form other If you are a nonresident alien or a foreign entity,give the requester the than Form W-9 to request your TIN,you must use the requester's form if appropriate completed Form W-8 or Form 8233. it is substantially similar to this Form W-9. Backup Withholding Definition of a U.S.person.For federal tax purposes,you are considered a U.S.person if you are: What is backup withholding?Persons making certain payments to you •An individual who is a U.S.citizen or U.S.resident alien; must under certain conditions withhold and pay to the IRS 24%of such payments.This is called"backup withholding." Payments that may be •A partnership,corporation,company,or association created or subject to backup withholding include interest,tax-exempt interest, organized in the United States or under the laws of the United States; dividends,broker and barter exchange transactions,rents,royalties, •An estate(other than a foreign estate);or nonemployee pay,payments made in settlement of payment card and •A domestic trust(as defined in Regulations section 301.7701-7). third party network transactions,and certain payments from fishing boat operators.Real estate transactions are not subject to backup Special rules for partnerships.Partnerships that conduct a trade or withholding. business in the United States are generally required to pay a withholding You will not be subject to backup withholding on payments you tax under section 1446 on any foreign partners'share of effectively receive if you give the requester your correct TIN,make the proper connected taxable income from such business.Further,in certain cases certifications,and report all your taxable interest and dividends on your where a Form W-9 has not been received,the rules under section 1446 tax return. require a partnership to presume that a partner is a foreign person,and pay the section 1446 withholding tax.Therefore,if you are a U.S.person Payments you receive will be subject to backup withholding if: that is a partner in a partnership conducting a trade or business in the 1.You do not furnish your TIN to the requester, United States,provide Form W-9 to the partnership to establish your 2.You do not certify your TIN when required(see the instructions for U.S.status and avoid section 1446 withholding on your share of Part II for details), partnership income. In the cases below,the following person must give Form W-9 to the 3.The IRS tells the requester that you furnished an incorrect TIN, partnership for purposes of establishing its U.S.status and avoiding 4.The IRS tells you that you are subject to backup withholding withholding on its allocable share of net income from the partnership because you did not report all your interest and dividends on your tax conducting a trade or business in the United States. return(for reportable interest and dividends only),or •In the case of a disregarded entity with a U.S.owner,the U.S,owner 5.You do not certify to the requester that you are not subject to of the disregarded entity and not the entity; backup withholding under 4 above(for reportable interest and dividend •In the case of a grantor trust with a U.S.grantor or other U.S.owner, accounts opened after 1983 only). generally,the U.S.grantor or other U.S.owner of the grantor trust and Certain payees and payments are exempt from backup withholding. not the trust;and See Exempt payee code, later,and the separate Instructions for the •In the case of a U.S.trust(other than a grantor trust),the U.S.trust Requester of Form W-9 for more information. (other than a grantor trust)and not the beneficiaries of the trust. Also see Special rules for partnerships, earlier. Foreign person.If you are a foreign person or the U.S.branch of a What is FATCA Reporting? foreign bank that has elected to be treated as a U.S.person,do not use Form W-9.Instead,use the appropriate Form W-8 or Form 8233(see The Foreign Account Tax Compliance Act(FATCA)requires a Pub.515,Withholding of Tax on Nonresident Aliens and Foreign participating foreign financial institution to report all United States Entities). account holders that are specified United States persons.Certain Nonresident alien who becomes a resident alien.Generally,only a payees are exempt from FATCA reporting.See Exemption from FATCA nonresident alien individual may use the terms of a tax treaty to reduce reporting code, later,and the Instructions for the Requester of Form or eliminate U.S.tax on certain types of income.However,most tax W-9 for more information. treaties contain a provision known as a"saving clause."Exceptions Updating Your Information specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise You must provide updated information to any person to whom you become a U.S,resident alien for tax purposes. claimed to be an exempt payee if you are no longer an exempt payee If you are a U.S.resident alien who is relying on an exception and anticipate receiving reportable payments in the future from this contained in the saving clause of a tax treaty to claim an exemption person.For example,you may need to provide updated information if from U.S.tax on certain types of income,you must attach a statement you are a C corporation that elects to be an S corporation,or if you no to Form W-9 that specifies the following five items. longer are tax exempt.In addition,you must furnish a new Form W-9 if 1.The treaty country.Generally,this must be the same treaty under the name or TIN changes for the account;for example,if the grantor of a which you claimed exemption from tax as a nonresident alien. grantor trust dies. 2.The treaty article addressing the income. Penalties 3.The article number(or location)in the tax treaty that contains the saving clause and its exceptions. Failure to furnish TIN.If you fail to furnish your correct TIN to a 4.The type and amount of income that qualifies for the exemption requester,you are subject to a penalty of$50 for each such failure from tax. unless your failure is due to reasonable cause and not to willful neglect. 5.Sufficient facts to justify the exemption from tax under the terms of Civil penalty for false information with respect to withholding.If you the treaty article, make a false statement with no reasonable basis that results in no backup withholding,you are subject to a$500 penalty. 23 Form W-9(Rev.10-2018) Page 3 Criminal penalty for falsifying information.Willfully falsifying IF the entity/person on line 1 is THEN check the box for... certifications or affirmations may subject you to criminal penalties a(n)... including fines and/or imprisonment. Misuse of TINs.If the requester discloses or uses TINs in violation of • Corporation Corporation federal law,the requester may be subject to civil and criminal penalties. • Individual Individual/sole proprietor or single- * Sole proprietorship,or member LLC Specific Instructions • Single-member limited liability company(LLC)owned by an Line 1 individual and disregarded for U.S. You must enter one of the following on this line;do not leave this line federal tax purposes. blank.The name should match the name on your tax return. LLC treated as a partnership for Limited liability company and enter If this Form W-9 is for a joint account(other than an account U.S,federal tax purposes, the appropriate tax classification. maintained by a foreign financial institution(FFI)), list first,and then LLC that has filed Form 8832 or (P=Partnership;C=C corporation; circle,the name of the person or entity whose number you entered in 2553 to be taxed as a corporation, or S=S corporation) Part I of Form W-9.If you are providing Form W-9 to an FFI to document or a joint account,each holder of the account that is a U.S.person must • LLC that is disregarded as an provide a Form W-9. entity separate from its owner but a. Individual.Generally,enter the name shown on your tax return.If the owner is another LLC that is you have changed your last name without informing the Social Security not disregarded for U.S.federal tax Administration(SSA)of the name change,enter your first name,the last purposes. name as shown on your social security card,and your new last name. Note:ITIN applicant:Enter your individual name as it was entered on Partnership Partnership your Form W-7 application, line 1 a.This should also be the same as the Trust/estate Trust/estate name you entered on the Form 1040/1040A/1040EZ you filed with your Line 4, Exemptions application. b. Sole proprietor or single-member LLC.Enter your individual If you are exempt from backup withholding and/or FATCA reporting, name as shown on your 1040/1040A/1040EZ on line 1.You may enter enter in the appropriate space on line 4 any code(s)that may apply to your business,trade,or"doing business as"(DBA)name on line 2. you. c. Partnership,LLC that is not a single-member LLC,C Exempt payee code. corporation,or S corporation.Enter the entity's name as shown on the Generally,individuals(including sole proprietors)are not exempt from entity's tax return on line 1 and any business,trade,or DBA name on backup withholding. line 2. Except as provided below,corporations are exempt from backup d. Other entities.Enter your name as shown on required U.S,federal withholding for certain payments,including interest and dividends. tax documents on line 1.This name should match the name shown on the Corporations are not exempt from backup withholding for payments charter or other legal document creating the entity.You may enter any made in settlement of payment card or third party network transactions. business,trade,or DBA name on line 2. • Corporations are not exempt from backup withholding with respect to e. Disregarded entity.For U.S.federal tax purposes,an entity that is attorneys'fees or gross proceeds paid to attorneys,and corporations disregarded as an entity separate from its owner is treated as a that provide medical or health care services are not exempt with respect "disregarded entity." See Regulations section 301.7701-2(c)(2)(iii).Enter to payments reportable on Form 1099-MISC. the owner's name on line 1.The name of the entity entered on line 1 should never be a disregarded entity.The name on line 1 should be the The following codes identify payees that are exempt from backup name shown on the income tax return on which the income should be withholding.Enter the appropriate code in the space in line 4. reported.For example,if a foreign LLC that is treated as a disregarded 1—An organization exempt from tax under section 501(a),any IRA,or entity for U.S,federal tax purposes has a single owner that is a U.S. a custodial account under section 403(b)(7)if the account satisfies the person,the U.S.owner's name is required to be provided on line 1.If requirements of section 401(f)(2) the direct owner of the entity is also a disregarded entity,enter the first 2—The United States or any of its agencies or instrumentalities owner that is not disregarded for federal tax purposes.Enter the disregarded entity's name on line 2,"Business name/disregarded entity 3—A state,the District of Columbia,a U.S.commonwealth or name."If the owner of the disregarded entity is a foreign person,the possession,or any of their political subdivisions or instrumentalities owner must complete an appropriate Form W-8 instead of a Form W-9. 4—A foreign government or any of its political subdivisions,agencies, This is the case even if the foreign person has a U.S.TIN. or instrumentalities Line 2 5—A corporation If you have a business name,trade name,DBA name,or disregarded 6—A dealer in securities or commodities required to register in the entity name,you may enter it on line 2. United States,the District of Columbia,or a U.S.commonwealth or possession Line 3 7—A futures commission merchant registered with the Commodity Check the appropriate box on line 3 for the U.S.federal tax Futures Trading Commission classification of the person whose name is entered on line 1.Check only 8—A real estate investment trust one box on line 3. 9—An entity registered at all times during the tax year under the Investment Company Act of 1940 10—A common trust fund operated by a bank under section 584(a) 11—A financial institution I 12—A middleman known in the investment community as a nominee or custodian 13—A trust exempt from tax under section 664 or described in section 4947 i i 24 Form W-9(Rev.10-2018) Page 4 The following chart shows types of payments that may be exempt M—A tax exempt trust under a section 403(b)plan or section 457(g) from backup withholding.The chart applies to the exempt payees listed plan above,1 through 13. Note:You may wish to consult with the financial institution requesting IF the payment is for... THEN the payment is exempt this form to determine whether the FATCA code and/or exempt payee for... code should be completed. Interest and dividend payments All exempt payees except Line 5 for 7 Enter your address(number,street,and apartment or suite number). Broker transactions Exempt payees 1 through 4 and 6 This is where the requester of this Form W-9 will mail your information through 11 and all C corporations. returns.If this address differs from the one the requester already has on S corporations must not enter an file,write NEW at the top.If a new address is provided,there is still a exempt payee code because they chance the old address will be used until the payor changes your are exempt only for sales of address in their records. noncovered securities acquired Line 6 prior to 2012. Barter exchange transactions and Exempt payees 1 through 4 Enter your city,state,and ZIP code. patronage dividends Part 1. Taxpayer Identification Number (TIN) Payments over$600 required to be Generally,exempt payees Enter your TIN in the appropriate box.If you are a resident alien and reported and direct sales over 1 through 52 you do not have and are not eligible to get an SSN,your TIN is your IRS $5,0001 individual taxpayer identification number(]TIN).Enter it in the social security number box. If you do not have an ITIN,see How to get a TIN Payments made in settlement of Exempt payees 1 through 4 below. payment card or third party network If you are a sole proprietor and you have an EIN,you may enter either transactions your SSN or EIN. 1 See Form 1099-MISC,Miscellaneous Income,and its instructions. If you are a single-member LLC that is disregarded as an entity separate from its owner,enter the owner's SSN(or EIN,if the owner has z However,the following payments made to a corporation and one).Do not enter the disregarded entity's EIN.If the LLC is classified as reportable on Form 1099-MISC are not exempt from backup a corporation or partnership,enter the entity's EIN. withholding:medical and health care payments,attorneys'fees,gross Note:See What Name and Number To Give the Requester, later,for proceeds paid to an attorney reportable under section 6045(f),and further clarification m name and TIN combinations. payments for services paid by a federal executive agency. Exemption from FATCA reporting code.The following codes identify How to get a TIN.If you do not have a TIN,apply for one immediately. payees that are exempt from reporting under FATCA.These codes To apply for an SSN,get Form SS-5,Application for a Social Security apply to persons submitting this form for accounts maintained outside Card,from your local SSA office or get this form online at of the United States by certain foreign financial Institutions.Therefore,if www.SSA.gov.You may also get this form by calling 1-800-772-1213. you are only submitting this form for an account you hold in the United Use Form W-7,Application for IRS Individual Taxpayer Identification States,you may leave this field blank.Consult with the person Number,to apply for an ITIN,or Form SS-4,Application for Employer requesting this form if you are uncertain if the financial institution is Identification Number,to apply for an EIN.You can apply for an EIN subject to these requirements.A requester may indicate that a code is online by accessing the IRS website at www.irs.gov/Businesses and not required by providing you with a Form W-9 with"Not Applicable"(or clicking on Employer Identification Number(EIN)under Starting a any similar indication)written or printed on the line for a FATCA Business.Go to www.irs.gov/Forms to view,download,or print Form exemption code. W-7 and/or Form SS-4. Or,you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 A—An organization exempt from tax under section 501(a)or any business days. individual retirement plan as defined in section 7701(a)(37) If you are asked to complete Form W-9 but do not have a TIN,apply B—The United States or any of its agencies or instrumentalities for a TIN and write"Applied For"in the space for the TIN,sign and date C—A state,the District of Columbia,a U.S.commonwealth or the form,and give it to the requester.For interest and dividend possession,or any of their political subdivisions or instrumentalities payments,and certain payments made with respect to readily tradable D—A corporation the stock of which is regularly traded on one or instruments,generally you will have 60 days to get a TIN and give it to more established securities markets,as described in Regulations the requester before you are subject to backup withholding on section 1.1472-1(c)(1)(1) payments.The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until E—A corporation that is a member of the same expanded affiliated you provide your TIN to the requester. group as a corporation described in Regulations section 1.1472-1(c)(1)(i) Note:Entering"Applied For"means that you have already applied for a F—A dealer in securities,commodities,or derivative financial TIN or that you intend to apply for one soon. instruments(including notional principal contracts,futures,forwards, and options)that is registered as such under the laws of the United Caution:A disregarded U.S.entity that has a foreign owner must use States or any state the appropriate Form W-8. G—A real estate investment trust Part II. Certification H—A regulated investment company as defined in section 851 or an To establish to the withholding agent that you are a U.S.person,or entity registered at all times during the tax year under the Investment resident alien,sign Form W-9.You may be requested to sign by the Company Act of 1940 withholding agent even if item 1,4,or 5 below indicates otherwise. I—A common trust fund as defined in section 584(a) For a joint account,only the person whose TIN is shown in Part I J—A bank as defined in section 581 should sign(when required). In the case of a disregarded entity,the K—A broker person identified on line 1 must sign.Exempt payees,see Exempt payee L—A trust exempt from tax under section 664 or described in section code, earlier. 4947(a)(1) Signature requirements.Complete the certification as indicated in items 1 through 5 below. 25 Form W-9(Rev.10-2018) Page 5 1.Interest,dividend,and barter exchange accounts opened For this type of account: Give name and EIN of: before 1984 and broker accounts considered active during 1983. 14.Account with the Department of The public entity You must give your correct TIN,but you do not have to sign the Agriculture in the name of a public certification. entity(such as a state or local 2.Interest,dividend,broker,and barter exchange accounts government,school district,or opened after 1983 and broker accounts considered inactive during prison)that receives agricultural 1983.You must sign the certification or backup withholding will apply.If program payments you are subject to backup withholding and you are merely providing your correct TIN to the requester,you must cross out item 2 in the 15.Grantor trust filing under the Form The trust certification before signing the form. 1041 Filing Method or the Optional 3.Real estate transactions.You must sign the certification.You may Form 1099 Filing Method 2(see 4 Regulations section 1.671-4(b)(2)(i)(B)) cross out item 2 of the certification. 4.Other payments.You must give your correct TIN,but you do not 'List first and circle the name of the person whose number you furnish. have to sign the certification unless you have been notified that you If only one person on a joint account has an SSN,that person's number have previously given an incorrect TIN."Other payments"include must be furnished. payments made in the course of the requester's trade or business for 2 Circle the minor's name and furnish the minor's SSN. rents,royalties,goods(other than bills for merchandise),medical and health care services(including payments to corporations),payments to a You must show your individual name and you may also enter your a nonemployee for services,payments made in settlement of payment business or DBA name on the"Business name/disregarded entity" card and third party network transactions,payments to certain fishing name line.You may use either your SSN or EIN(if you have one),but the boat crew members and fishermen,and gross proceeds paid to IRS encourages you to use your SSN. attorneys(including payments to corporations). 4 List first and circle the name of the trust,estate,or pension trust.(Do 5.Mortgage interest paid by you,acquisition or abandonment of not furnish the TIN of the personal representative or trustee unless the secured property,cancellation of debt,qualified tuition program legal entity itself is not designated in the account title.)Also see Special payments(under section 529),ABLE accounts(under section 529A), rules for partnerships,earlier. IRA,Coverdell ESA,Archer MSA or HSA contributions or *Note:The grantor also must provide a Form W-9 to trustee of trust. distributions,and pension distributions.You must give your correct Note:If no name is circled when more than one name is listed,the TIN,but you do not have to sign the certification, number will be considered to be that of the first name listed. What Name and Number To Give the Requester Secure Your Tax Records From Identity Theft For this type of account: Give name and SSN of: Identity theft occurs when someone uses your personal information 1.Individual The Individual such as your name,SSN,or other identifying information,without your 2.Two or more individuals(Joint The actual owner of the account or,if permission,to commit fraud or other crimes.An identity thief may use account)other than an account combined funds,the first individual on your SSN to get a job or may file a tax return using your SSN to receive maintained by an FFIthe account' a refund. 3.Two or more U.S.persons Each holder of the account To reduce your risk: (Joint account maintained by an FFI) •Protect your SSN, 4.Custodial account of a minor The minor2 •Ensure your employer is protecting your SSN,and (Uniform Gift to Minors Act) •Be careful when choosing a tax preparer. 5.a.The usual revocable savings trust The grantor-trustee' If your tax records are affected by identity theft and you receive a (grantor is also trustee) notice from the IRS,respond right away to the name and phone number b.So-called trust account that is not The actual owner printed on the IRS notice or letter. a legal or valid trust under state law If your tax records are not currently affected by identity theft but you 6.Sole proprietorship or disregarded The owner3 think you are at risk due to a lost or stolen purse or wallet,questionable entity owned by an individual credit card activity or credit report,contact the IRS Identity Theft Hotline 7.Grantor trust filing under Optional The grantor* at 1-800-908-4490 or submit Form 14039. Form 1099 Filing Method 1(see For more information,see Pub.5027, Identity Theft Information for Regulations section 1.671-4(b)(2)(i) Taxpayers. (A)) Victims of identity theft who are experiencing economic harm or a For this type of account: Give name and EIN of: systemic problem,or are seeking help in resolving tax problems that s.Disregarded entity not owned by an The owner have not been resolved through normal channels,may be eligible for individual Taxpayer Advocate Service(TAS)assistance,You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 9.A valid trust,estate,or pension trust Legal entity° 1-800-829-4059. 10.Corporation or LLC electing The corporation Protect yourself from suspicious emails or phishing schemes. corporate status on Form 8832 or Phishing is the creation and use of email and websites designed to Form 2553 mimic legitimate business emails and websites.The most common act 11.Association,club,religious, The organization is sending an email to a user falsely claiming to be an established charitable,educational,or other tax- legitimate enterprise in an attempt to scam the user into surrendering exempt organization private information that will be used for identity theft. 12.Partnership or multi-member LLC The partnership 13.A broker or registered nominee The broker or nominee 1 26 Form W-9(Rev.10-2018) Page 6 The IRS does not initiate contacts with taxpayers via emails.Also,the Privacy Act Notice IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers,passwords,or similar secret access Section 6109 of the Internal Revenue Code requires you to provide your information for their credit card,bank,or other financial accounts. correct TIN to persons(including federal agencies)who are required to If you receive an unsolicited email claiming to be from the IRS, file information returns with the IRS to report interest,dividends,or forward this message to phishing@irs.gov.You may also report misuse certain other income paid to you;mortgage interest you paid;the of the IRS name,logo,or other IRS property to the Treasury Inspector acquisition or abandonment of secured property;the cancellation of General for Tax Administration(TIGTA)at 1-800-366-4484.You can debt;or contributions you made to an IRA,Archer MSA,or HSA.The forward suspicious emails to the Federal Trade Commission at person collecting this form uses the information on the form to file spam@uce.gov or report them at www.ftc.gov/complaint.You can information returns with the IRS,reporting the above information. contact the FTC at www.ftc.gov/idtheft or 877-IDTH EFT(877-438-4338). Routine uses of this information include giving it to the Department of If you have been the victim of identity theft,see www.ldentityTheft.gov Justice for civil and criminal litigation and to cities,states,the District of and Pub.5027. Columbia,and U.S,commonwealths and possessions for use in administering their laws.The information also may be disclosed to other Visit www.irs.govIldentityTheft to learn more about identity theft and countries under a treaty,to federal and state agencies to enforce civil how to reduce your risk. and criminal laws,or to federal law enforcement and intelligence agencies to combat terrorism.You must provide your TIN whether or not you are required to file a tax return.Under section 3406,payers must generally withhold a percentage of taxable interest,dividend,and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.