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2023-451-E-Social Svc-Inter-faith Council for Social Service-outside agency funding & emergency assistance program
Inter-Faith Council for Social Services, Inc. Orange County Outside Agency Performance Agreement Revised77/2018 OUTSIDE AGENCY PERFORMANCE AGREEMENT THIS AGREEMENT, made and entered into the first day of July 2023, (“Effective Date”) by and between the County of Orange, a political subdivision of the State of North Carolina, 200 South Cameron Street, Hillsborough, North Carolina, 27278, ("County") and Inter-Faith Council for Social Services, Inc., a not-for- profit corporation, located at 110 West Main Street, Carrboro, NC 27510 (“Provider”). WITNESSETH: WHEREAS, it is in the interests of the County that said program be assisted by the County and thereby enhance its availability to residents of the County, and said program addresses an important community human services need, as identified by the Board of Commissioners; NOW, THEREFORE, in consideration of the above and the mutual covenants and conditions hereafter set forth, the County and Provider agree as follows: 1. Term of the Agreement. The term of this Agreement shall be a program year beginning July 1, 2023 to June 30, 2024. 2. Scope of Services. a. Provider will provide services to the residents of Orange County, as outlined in the Outside Agency Funding Application and any amendments or revision thereto (Exhibit “A”) and Emergency Assistance Scope of Work (“Exhibit B”), both of which are attached and hereby incorporated into this document as if set out herein. The Scope of Services in Exhibit A and the Program Budget may be different from the original application based on County appropriation; however, any revisions or amendments to this Agreement must be approved in writing by the County and attached to this Agreement as Exhibit C. b. The Provider shall be solely responsible for the means, methods, techniques, sequence, safety program and procedures necessary to properly and fully complete the work set forth in the Scope of Services. 3. Funding. a. The County agrees to appropriate funds for the provision of services described in Exhibit A, Scope of Services, and more particularly described in the Program Budget or Revised Program Budget, the maximum sum of Seventy Five Thousand Dollars ($75,000). The County also agrees to appropriate funds for the provision of services described in Exhibit B, the maximum sum of Eighty Five Thousand Dolloars ($85,000). The total amounted appropriated by the County to Provider for these services shall be One Hundred and Sixty Thousand Dollars ($160,000). b. All funds appropriated shall be used for purposes described in Exhibit A and Exhibit B. Any funds not used for the purposes stated shall be returned to the County. Any changes in the use of funds must be authorized in writing by the County prior to any expenditure of the funds by the Provider. If the funds are expended not in accordance with the Scope of Services provided in Exhibits A and B, at the discretion of the County the Provider may be required to repay the funds to the County. c. Funds Appropriated for Outside Agency Funding (Exhibit A) Services. DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 2 i. For funds appropriated for Exhibit A services, the Provider shall be paid in four equal installments in the amount of 18,750. The first payment is contingent upon receipt of the agency’s performance agreement; the remaining payments are contingent upon receipt of the request for reimbursement and related supporting documentation. ii. The County’s obligation to make the quarterly payments is contingent upon receipt of Progress Reports, which show satisfactory progress toward completion of performance measures and an accounting of expenditures as detailed in the attached Scope of Services. iii. Once Provider has satisfied its obligations as provided in c.1. above payment will be made 21 days after receipt of the Progress Report and Request for Reimbursement or 21 days after due date of Progress Report whichever is later. d. Funds Appropriated for Emergency Assistance (Exhibit B) Services. i. For funds appropriated for Exhibit B services, the County will reimburse Provider for services described in Exhibit B up to the limits allocated by this Agreement. Provider shall only be reimbursed for actual expenditures for approved services. ii. For reimbursement, Provider must submit copies of bills, checks, receipts and/or other proof of expenditures to the person designated by the County. Reimbursement will be provided bimonthly. iii. For reimbursement of staff costs, Provider shall submit the payment records for staff cost. The County will reimburse the Provider monthly upon receipt of a complete and correctly filed report. e. The County is not obligated to provide any other support to Provider in this or in succeeding fiscal years. 4. Agency Reporting. a. Provider will provide Orange County a Progress Report that includes a fiscal report and updates on performance measures as outlined in the Scope of Services. Progress Report dates are: July 1 – December 31; January 1 – March 31 and April 1 - June 30. Reports are due on January 10, April 10, and July 10 of the program fiscal year. b. Provider agrees to allow the County to inspect its financial books and records, which document costs of those services, upon reasonable notice during normal working hours. 5. Termination. a. In the event of any of the circumstances set forth below (hereinafter referred to as “default”), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 3 ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten (10) business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County’s remedies in law or in equity. c. Notwithstanding the foregoing, either party may terminate the agreement at any time without penalty; provided that written notice of such termination is furnished to the other party at least 30 days prior to termination. In the event of such termination, any payment due shall be prorated to the date of termination and any unused funds shall be returned to the County within 10 days of termination. d. Any termination of this Agreement for default under this section that is later deemed to be unjustified shall be deemed a termination for convenience. 6. Insurance. a. General Requirements. The Provider shall purchase and maintain, during the period of performance of this Agreement, insurance: i. Worker’s Compensation. For protection from claims under workers' or workmen's compensation acts; ii. Comprehensive General Liability Insurance covering claims arising out of or relating to bodily injury, including bodily injury, sickness, disease or death of any of the Consultant's employees or any other person and to real and personal property including loss of use resulting thereof; iii. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and iv. Professional Liability Insurance, covering personal injury, bodily injury and property damage and claims arising out of or related to the performance under this Agreement by the Consultant or his agents, consultants and employees. b. Limits of Coverage: Minimum limits of insurance coverage shall be as follows: DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 4 INSURANCE DESCRIPTION MINIMUM REQUIRED COVERAGE • Worker's Compensation Limits for Coverage A - Statutory State NC & Coverage B - Employers Liability $500,000 each accident, disease policy limit and disease each employee • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $500,000 Combined Single Limit • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate c. All insurance policies (with the exception of Worker's Compensation and Professional Liability) required under this Agreement shall name the County as an additional insured party and as a certificate holder. Evidence of such insurance and all correspondence shall be sent to: Orange County Risk Manager Post Office Box 8181 Hillsborough, NC 27278 d. Nothing in this section is intended to affect or abrogate the County’s sovereign immunity defenses. 7. Relationship of the Parties. Provider is an independent contractor of the County. Provider represents that they have or will secure, at his own expense, all personnel required in performing the services under this Agreement. Such personnel shall not be employees or have any contractual relationship with the County. All personnel engaged in work under this Agreement shall be fully qualified and shall be authorized and permitted under federal, state and local law to perform such services. 8. Compliance with all Laws. The Provider, at its sole expense, shall comply with all laws, ordinances, orders and regulations of the federal, state or local governments, as well as their respective departments, commissions, boards, and officers, which are in effect at the time of execution of this Agreement or are adopted at any time following execution of this agreement. 9. Subcontract. The County and Provider deem the services provided under this Agreement to be personal in nature and Provider may not subcontract any rights or duties under this Agreement to any other party without prior written consent from the County. 10. Assignment. The Provider shall not assign this Agreement, including the rights to payment, to any other party without the prior written consent of the County. 11. Indemnification. Provider agrees to defend, indemnify, and hold harmless the County, for all loss, liability, claims or expense (including reasonable attorney's fees) arising from bodily injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County’s sovereign immunity defenses. 12. Non-Appropriation. This Agreement is subject to the availability of funds to purchase the specified services and may be terminated at any time if such funds become unavailable. DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 5 13. Non-Discrimination. Provider agrees as part of consideration of the granting of funds by Orange County the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Non-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. 14. Living Wage. Orange County is committed to providing its employees with a living wage and encourages agencies if funds to pursue the same goal. The County’s living wage is $ 14.95 per hour. To the extent possible, Orange County recommends that Provider provide a living wage to its employees. 15. Notice. The Parties hereto agree and understand that written notice, mailed or delivered, to the last known address shall constitute sufficient notice to the County and the Provider. All notices required and/or made pursuant to this Agreement to be given to the County and the Provides shall be in writing and mailed to the party addressed as follows: County: Provider: Nancy Coston Executive Director Department of Social Services The Inter-Faith Council for Social Orange County Service, Inc. Post Office Box 8181 110 W. Main Street Hillsborough, North Carolina 27278 Carrboro, North Carolina 27510 16. Entire Agreement. This Agreement, including any referenced attachments, constitutes the entire Agreement between the parties and shall supersede, replace or nullify any and all prior Agreements of understandings; written or oral, relating to the matters set forth herein, and any such prior Agreements or understandings shall have no force or affect whatsoever on this Agreement. The County and Provider have read this Agreement and agree to be bound by all of its terms, and further agree that this Agreement constitutes the complete and exclusive statement of the Agreement between the County and Provider. 17. Severability. All clauses found herein shall act independently of each other. If a clause is found to be illegal or unenforceable, it shall have no effect on the other provisions of this Agreement. It is understood by the parties hereto that if any part, term or provision of this Agreement is by the Courts held to be illegal or in conflict with any laws of the State of North Carolina or the United States, the validity of the remaining portions or provisions shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if the Agreement did not contain the particular part, term or provision held to be invalid. 18. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php). Any violation of this requirement is a breach of the Agreement and County may immediately DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 6 terminate this Agreement without further obligation on part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 19. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. IN WITNESS WHEREOF, the Orange County and the Provider have signed this Agreement, effective on the last date this Agreement is signed by both parties as indicated by the dates set forth under signatures below. For and on behalf of the Provider _____________________________ _______________________ Jackie Jenks, Executive Director Date For and on behalf of Orange County Government _______________________________ ________________________ Bonnie Hammersley, County Manager Date DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 8/23/2023 8/26/2023 Revised 04/23 1 ORANGE COUNTY—INTERNAL USE ONLY ______________________________________________________________________________ Finance Information Vendor Name: Inter-faith Council for Social Service, Inc. Vendor Contact Person: Jackie Jenks Phone: 919-919- 6380 Address: 110 West Main Street City Carrboro State: NC Zip: 27510 Department: Social Services Amount: $160,000 Purpose: outside agency funding & emergency assistance program Budget Code(s): 10403020-630000 Vendor # 1149 Vendor Status with NCSOS: Current-Active Vendor is a BOCC consultant: Yes No Contract Details Contract Type: New Amendment (Original Contract: ) (Most Recent Amendment ) Effective Date 7/1/23 End Date 6/30/24 Notice Date (Notice Purpose ) Award Approved by Board (Agenda Date: 6/20/23); Made or Administered by Signature Authority - BOCC Express Delegation (Agenda Date: ) - Policy 9.4: Under $5,000; Service Under $90,000; Construction Under $250,000 - Budget Policy Section XV (Capital Improvement Project: ) Bidding Informal Bidding ($30k-$90k); Formal RFP ($90k+); Other (<$30k); Exception(# ) Department Affirmation 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. Services related to this agreement have already begun or been completed. Description of the nature of the emergency condition that was addressed: Department Director’s Signature ________________________________________ Date: ________ Information Technologies This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Inapplicable because no hardware/software purchases or related services 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 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: Received for record retention: Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 8/23/2023 8/24/2023 8/25/2023 8/25/2023 Orange County Outside Agency Performance Agreement Page 8 of 10 Rev.06/23 Exhibit A Provider’s Outside Agency Application DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Cover Page P a g e 6 o f 3 2 COVER PAGE Applicant Contact Information Applicant Organization’s Legal Name: Inter-Faith Council for Social Service Applicant Organization’s Physical Address: 110 W Main St, Carrboro, NC 27510 Applicant Organization’s Mailing Address: 110 W Main St, Carrboro, NC 27510 Applicant Organization’s Web Address: www.ifcweb.org Executive Director: Jackie Jenks, President and CEO Telephone Number: 919.929.6380 E-Mail: jjenks@ifcmailbox.org Tax ID Number: 59-1224041 Funding Request Please list all Fiscal Year 2024 Human Services (HS) funding requested for all programs and the proposed use of funds (please list program name only) Program Carrboro - HS Chapel Hill - HS Orange County- HS Total Ex. Youth Afterschool Program Operations or Personnel $10,000 Operations $15,000 Personnel $5,000 Operations $30,000 Shelters Personnel $81,378 $225,923 $224,785 $532,086 Shelters Operations $14,361 $39,869 $39,668 $93,898 Food Programs Personnel $20,250 $23,490 $60,750 $104,490 Food Programs Operations $4,750 $5,510 $14,250 $24,510 Totals $120,739 $294,792 $339,453 $754,984 Briefly explain your proposed use of funds: IFC continues to be the sole provider of shelter in Orange County and the primary non-profit provider of daily hot meals, a free-of-charge community market, and emergency financial assistance in Chapel Hill and Carrboro. Employing a racial equity and social justice lens, we provide the most comprehensive set of non-profit social safety net services in Orange County, while simultaneously working to address the root causes of poverty through housing, advocacy, and civic engagement. Funds will assure we’re able to continue providing these crucial programs for people living and working in our community. DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Cover Page P a g e 8 o f 3 2 DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON-DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates. YES NO a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? c) Current beneficiaries of the program for which funds are being requested? d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. x Embracing a commitment to equity and representation of all stakeholder perspectives, IFC prioritizes including recipients of services and others with lived experience on our Board of Directors. One member of our Board accesses IFC services. x Some of our part-time shelter staff members are employed by Orange County. x One of our part-time employees is a council member in Chapel Hill. However, they do not work in any program for which IFC has requested Outside Agency funding, nor will any of their wages be paid through public funding of any kind. NON-DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Cover Page P a g e 1 0 o f 3 2 AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year): IFC was founded in 1963 and was incorporated in November 1970. 2. Agency’s Purpose/Mission (no more than a few sentences): IFC confronts the causes and responds to the effects of poverty in our community. We believe in a community that meets everyone's basic needs, including dignified and affordable housing, an abundance of healthy food, and meaningful social connection. 3. Please provide a brief description of your organization’s past achievements in carrying out similar projects and evidence of successful record of meeting proposed budgets and timetables (no more than 100 words). In 1963, seven women united to address poverty in Chapel Hill and Carrboro. Since then, IFC has become the primary non-profit provider of basic needs services for people in our community. IFC has built capacity over decades to respond to residents’ diverse needs in partnership with local congregations, foundations, individuals, businesses, partner service providers, and governments. Five years ago, we shifted to a social justice model, where all stakeholders shape IFC practices through a racial equity lens. We respond to food and housing inequities through direct services, as well as advocacy to address the root causes of these inequities. 4. Living Wage: Does this agency pay permanent employees a minimum living wage? (Yes / No) Yes, proudly If yes, is this agency an Orange County Living Wage Certified Employer? Yes, proudly If no, please briefly explain. Schedule of Positions: # of FTE – Full-Time Paid Positions: 34 # of FTE – Part-Time Paid Positions: 11 Race & Equity Consistent with our commitment to equity and inclusion, the Towns of Chapel Hill and Carrboro and Orange County Government are taking steps together to center racial equity in the Human Services Funding Program. We are requesting basic information about your organization’s racial equity work. 5. How has your organization incorporated racial equity goals into your organizational goals? DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Cover Page P a g e 1 1 o f 3 2 IFC’s "Approach" document operationalizes our mission, vision, and values which focus on equity and social justice. In 2017, we held the first meeting of IFC’s R.E.A.L. (Race.Equity.Action.Leadership.) Transformation Team with a pro-bono consultant. The R.E.A.L. Transformation team's responsibility was to focus on racial equity and make recommendations to Board and Staff on changes to policies, procedures, and practices to advance equity and anti-racism within and beyond IFC. One of their projects was to create and conduct a Racial Equity Organizational Assessment for IFC, which facilitated conversations about racial equity at all levels of each of our programs – members, residents, volunteers, staff, and board. The R.E.A.L. Transformation Team evolved over time to form two affinity groups – a group centered around white-bodied experience and a BIPOC (Black, Indigenous, and People of Color) group - to start the difficult work of self-reflection and learning how to become a social justice organization. The two groups meet regularly and separately so that we can each do our own anti-racism work specific to our experiences. In addition to the affinity groups, in February some of us will begin the Finding Freedom Workshop which “aims to deepen our individual and collective understanding of how we as white women are complicit with white supremacy, how we can make changes to live more deeply and consistently into our racial justice commitments, and how we can move ourselves and other people in our networks to join the fight for racial, economic and gender justice right now” (https://www.wearefindingfreedom.org/workshops). We sponsor participation for staff, board members, volunteers, and members at racial equity trainings and other trainings and equity discussions are regularly part of staff, board, and volunteer meetings. We focus on racial equity values in our hiring and board recruitment process. We include our equity filter on each board meeting agenda, and have board members with experience doing anti-racism work in other realms. We recently increased our Community Engagement Manager to a Director position to elevate our efforts to onboard volunteers and build a social justice and anti-racism culture at IFC. We also increased our Activate! IFC Manager to a Director position and created Activate! IFC Manager positions in order to build capacity in our social justice work. Our Development and Communications department incorporates racial equity through social media posts, and we encourage all voices to be heard in our newsletters, including stories written by members. We embrace the principles of Community Centric Fundraising, such as “fundraising must be grounded in race, equity, and social justice” and “we foster a sense of belonging, not othering” (https://communitycentricfundraising.org/ccf-principles/). This past year we contracted with a culture change consultant to work with all stakeholder groups in creating our agency’s Theory of Action. 6. Please describe how you have involved the intended beneficiaries of the proposed project in the planning and design process (in 100 words or less). IFC’s community power value asserts that the people experiencing problems are best suited to lead us to solutions. We prioritize lived experience in hiring. IFC members are involved in day-to-day and higher-level agency decisions, such as co-creating programs DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Cover Page P a g e 1 2 o f 3 2 and services, advocating for changes to program policies, and serving on IFC hiring panels and our Board of Directors. We have conversations with members and get to know them from a place of mutual respect. When we build relationships in this way, people feel comfortable talking about their real needs and participating in solutions. 7. Please fill in your agency demographics in the table below: Agency Demographics Staff Board Gender Men 13 9 Women 32 8 Nonbinary/Genderqueer Self-Describe Total 45 17 Race and Ethnicity Black or African-American 31 5 American Indian or Alaska Native Asian Indian White 11 7 Native Hawaiian or Other Pacific Islander Chinese Japanese Vietnamese Filipino Korean Some other race 3 5 Total 45 17 Of the above, how many Hispanic, Latino or Spanish origin 2 2 Of the above, how many non-Hispanic, Latino or Spanish origin 43 15 Total 45 17 8. Please describe any activities your organization is doing to address racial equity. a. % of staff that have attended racial equity training: 100% b. % of board that have attended racial equity training: 100% c. Any additional activities: DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Cover Page P a g e 1 3 o f 3 2 Our Activate! IFC program helps us live out our mission by addressing the root causes of poverty, such as social and racial inequity. Activate! IFC is a civic engagement and leadership project that engages IFC members and residents with the goal of tapping into their leadership potential to become more involved in the political process. Activate! IFC projects work to demystify the policy-making process, remove barriers to decision-makers, and activate valuable marginalized voices in our community to advocate for themselves. Some examples of Activate! IFC events include House Us Now! Rallies and Walk to the Polls events. One of Activate! IFC’s programs is the Safety Vanguard Project. Our community is challenging us to rethink who, what, and how we keep each other safe. We are being called to envision a community not of law, order, and fear, but one that is protected by radical, non-punitive means of safety and justice. Through IFC’s Safety Vanguard Project, IFC members and residents will plug into leadership positions and advocate in groups working on this re-envisioning of community safety – groups such as Carrboro’s Community Safety Task Force (CSTF), the Orange County Bail Bond Justice Board, and NC CRED (North Carolina Commission on Racial and Ethnic Disparities in the Criminal Justice System). If we are to accomplish our goal of transforming community safety, then decision-making bodies require meaningful participation by those who are most impacted - those who are BIPOC, unsheltered, working class, and justice-involved; those who are most impacted by the realities of white supremacist capitalist patriarchy, police brutality, and the prison industrial complex. As the main resource for social safety net resources and a hub for social justice advocacy in our community, IFC is part of a network of community members who fit this description and are interested, willing, and able to lead. Three people in IFC’s community are already connected to these groups in official capacities and will serve as a connection to the larger IFC community. While it is critical that those most impacted by systems are at the decision-making table to lead us to solutions, we must keep in mind that folks most impacted are often called to speak on their lived experience in a way that tokenizes, re-traumatizes, and marginalizes. We must be intentional about how we activate each other in this work. Activate! IFC values the physical, mental, spiritual, and emotional health of our team and equips team members with the necessary tools that ground, center, and energize us toward social equity. We hold regular meetings to create space for folks to reflect, unpack, and strategize about the advocacy process. At these sessions, we equip folks with mental health, harm reduction, and mindfulness practices. Practically, we must provide equitable support to make it easier for folks to participate. This involves computers, cell phones, stipends and incentives, increased staff time, trainings, space, and food. Ultimately, we aim to impact our community with policies and decisions that shift power back to communities where, consistent with IFC’s value of community power, those who have been marginalized are the ones leading and putting forth solutions. DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Cover Page P a g e 1 4 o f 3 2 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 9. Program Name: Shelters Program Primary Contact and Title: Jessica Aldavé, Shelter and Housing Director Telephone Number:919.929.6380 E-Mail: jaldave@ifcmailbox.org 10.Please briefly describe the proposed program, including an explanation of how it aligns with the Town of Chapel Hill and Carrboro’s Results Framework, and Orange County BOCC Goals and Priorities, and the target population to benefit from the program. (250 words or less) As Orange County’s only provider of homeless shelter services, IFC works with numerous community partners to ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all county residents. IFC provides social safety net services required for economic and social well- being & opportunities to thrive, such as safe shelter and meals. IFC works with residents to identify their goals in increasing their livelihood security and access the most appropriate social safety net services, partly by participating in Orange County’s Coordinated Entry system, which determines quickly, consistently, and effectively which services or resources will best help people experiencing homelessness. We have worked with local governments over the past 3 years to provide shelter and safety against COVID- 19, to which people experiencing homelessness are especially vulnerable. This past year we worked with local governments to take a bigger role in financially supporting this work through our request for an inter-local agreement. 11. Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics Projected 2021-2022 Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 Gender Men 179 188 176 176 Women 80 90 80 80 Nonbinary/Genderqueer 0 3 3 3 Self-Describe 1 0 1 1 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Cover Page P a g e 1 5 o f 3 2 Total 260 281 260 260 Race and Ethnicity Black or African-American 160 175 160 160 American Indian or Alaska Native 3 4 3 3 Asian Indian Did not count Did not count N/A N/A White 83 84 83 83 Native Hawaiian or Other Pacific Islander 0 0 0 0 Chinese 2*Asian 2*Asian 2*Asian 2*Asian Japanese Vietnamese Filipino Korean Some other race 12 16 12 12 Total 260 281 260 260 Of the above, how many Hispanic, Latino or Spanish origin 7 8 7 7 Of the above, how many non-Hispanic, Latino or Spanish origin 253 273 253 253 Total 260 281 260 260 Age 0-5 years 14 24 14 14 6-18 years 18 16 18 18 19-50 years 136 140 136 136 51+ years 92 101 92 92 Total 260 281 260 260 Geographic Location Town of Chapel Hill 178 169 178 178 Town of Carrboro 11 8 11 11 Orange County (Outside of Chapel Hill/Carrboro)10 7 10 10 Outside of Orange County 61 97 61 61 Total 260 281 260 260 Income Low-income (80% of the Area Median Income and Below) Please see income table in the attachments 260 281 260 260 Total 260 281 260 260 12. Cost Per Individual DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Cover Page P a g e 1 6 o f 3 2 This cost per individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 Total Cost of Program $1,129,385 $1,382,298 $1,423,767 Total # of Individuals 281 260 260 Cost Per Individual $4,019 $5,317 $5,476 13. Performance Indicators For Chapel Hill and Carrboro applicants: Please complete the following chart with information about the Strategic Objective, Intermediate Result, and the Agency Performance Indicator for each program for which you are applying for funding. Please select one strategic objective per program.If you would like to provide additional information on how your program aligns with additional strategic objectives, please include that information in Question 10 – Program Description. See the Results Framework in the Attachments section as a reference. Program Name: Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes ܈ Residents Increase their livelihood security Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Insert Intermediate Result here. 2.1 Residents access the most appropriate social safety net services RESULTS Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 Performance Indicators (Please choose at least one performance indicator to report on from the Results Framework and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as needed, listing one per row). Insert Performance Indicator here. % and # of unduplicated community members who receive emergency shelter services 100% / 281* 100% / 260 100% / 260 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Cover Page P a g e 1 7 o f 3 2 % and # of program participants who are homeless or experiencing unstable housing who obtain Housing 25% / 57 30% / 78 30% / 78 *This number is for regular bed space at our shelters. In addition to regular bed space, we also provided 146 individuals with cold weather shelter space November through April. Please select which function area best aligns with your agency and program(s) in which you are requesting funding. Please select only one from the list below: տ Behavior Health ܆ Public Health & Health Educationտ Food & Nutritional Service տ Recreational ܈ Housing տ Senior Servicesտ Human Rights & Community Services տ Youth Services տ Juvenile & Adult Justice Services տ Other If you selected other, please tell us what function area best aligns with your organization: Please indicate three program goals/performance measures below. A few notes: x If you use percentages, please put the actual number equivalence. x Please ensure your performance measures are outcome based and not outputs. Program Goal # 1 Residents access the most appropriate social safety net services. Performance Measure (How will you accomplish your goal?) % and # of unduplicated community members who receive emergency shelter services DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Cover Page P a g e 1 8 o f 3 2 Actual Results (Outcome) Ending FY2022 100% / 281* Projected Results (Outcome) Ending FY2023 100% / 260 Projected Results (Outcome) Ending FY2024 100% / 260 *This number is for regular bed space at our shelters. In addition to regular bed space, we also provided 146 individuals with cold weather shelter space November through April. Program Goal # 2 Residents increase their livelihood security. Performance Measure (How will you accomplish your goal?) % and # of program participants who are homeless or experiencing unstable housing who obtain housing Actual Results (Outcome) Ending FY2022 25% / 57 Projected Results (Outcome) Ending FY2023 30% / 78 Projected Results (Outcome) Ending FY2024 30% / 78 Program Goal # 3 Residents access the most appropriate social safety net services. Performance Measure (How will you accomplish your goal?) % and # of unduplicated community members who receive access to cold weather cots Actual Results (Outcome) Ending FY2022 100% / 146 Projected Results (Outcome) Ending FY2023 100% / 150 Projected Results (Outcome) Ending FY2024 100% / 150 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Program information P a g e 1 9 o f 3 2 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 9. Program Name: Food Programs Program Primary Contact and Title: Kristin Lavergne, Community Services Director Telephone Number: 919.929.6380 E-Mail: klavergne@ifcmailbox.org 10. Please briefly describe the proposed program, including an explanation of how it aligns with the Town of Chapel Hill and Carrboro’s Results Framework, and Orange County BOCC Goals and Priorities, and the target population to benefit from the program. (250 words or less) As the largest non-profit provider of food security in our community for all residents, IFC ensures a community network of basic human services and infrastructure that maintains, protects, and promotes the well-being of all County residents. IFC’s Community Kitchen serves hot meals daily to anyone who is hungry, and the Community Market provides groceries, personal care items, and emergency financial assistance to prevent eviction and utility disruption. IFC’s food programs help ensure residents are accessing the most appropriate social safety net services, thereby advancing the towns’ priorities to increase residents’ livelihood security and support residents within and beyond IFC. Food security is necessary for residents’ economic and social well-being and their ability to take opportunities to thrive. Throughout the pandemic, we have continued food security services and met the increased needs of the community members who show up at our door. 11. Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics Projected 2021-2022 Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 Gender Men 1216 967 1216 1216 Women 1920 1354 1920 1920 Nonbinary/Genderqueer 0 13 0 0 Self-Describe 64 2 64 64 Total 3200 2336 3200 3200 Race and Ethnicity Black or African-American 1728 1187 1728 1728 American Indian or Alaska Native 32 34 32 32 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Program information P a g e 2 0 o f 3 2 Asian Indian Did not count Did not count N/A N/A White 928 713 928 928 Native Hawaiian or Other Pacific Islander 48 47 48 48 Chinese 48*Asia n 48*Asia n 48*Asian 48*Asia n Japanese Vietnamese Filipino Korean Some other race 416 307 416 416 Total 3200 2336 3200 3200 Of the above, how many Hispanic, Latino or Spanish origin 224 276 224 224 Of the above, how many non-Hispanic, Latino or Spanish origin 2976 2060 2976 2976 Total 3200 2336 3200 3200 Age 0-5 years 0 0 0 0 6-18 years 0 97 0 0 19-50 years 2176 1572 2176 2176 51+ years 1024 667 1024 1024 Total 3200 2336 3200 3200 Geographic Location Town of Chapel Hill 2250 1639 2250 2250 Town of Carrboro 850 578 850 850 Orange County (Outside of Chapel Hill/Carrboro) 60 62 60 60 Outside of Orange County 40 57 40 40 Total 3200 2336 3200 3200 Income Low-income (80% of the Area Median Income and Below) Please see income table in the attachments 3200 2336 3200 3200 Total 3200 2336 3200 3200 12. Cost Per Individual This cost per individual must reflect the total program budget divided by the total number of program individuals in this application. Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 Total Cost of Program $183,651 $401,874 $413,930 Total # of Individuals 2336 3200 3200 Cost Per Individual $78.62 $125.59 $129.35 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Program information P a g e 2 1 o f 3 2 13. Performance Indicators For Chapel Hill and Carrboro applicants: Please complete the following chart with information about the Strategic Objective, Intermediate Result, and the Agency Performance Indicator for each program for which you are applying for funding. Please select one strategic objective per program. If you would like to provide additional information on how your program aligns with additional strategic objectives, please include that information in Question 10 – Program Description. See the Results Framework in the Attachments section as a reference. Program Name: Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes ց Residents Increase their livelihood security Residents improve their health outcomes Intermediate Result (please choose one from the Results Framework) Insert Intermediate Result here. 2.1 Residents access the most appropriate social safety net services RESULTS Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 Performance Indicators (Please choose at least one performance indicator to report on from the Results Framework and add additional performance indicators that you would like to report to the Towns. Please insert additional rows as needed, listing one per row). Insert Performance Indicator here. % and # of households that receive food assistance (Market) 100% / 2,336 100% / 3,200 100% / 3,200 # meals provided/ food assistance (Kitchen) 100% / 48,754 100% / 54,000 100% / 54,000 % and # of individuals who receive emergency financial assistance for essential needs. 100% / 1,253 100% / 750 100% / 750 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Program information P a g e 2 2 o f 3 2 Please select which function area best aligns with your agency and program(s) in which you are requesting funding. Please select only one from the list below: տ Behavior Health ܆ Public Health & Health Education ܈ Food & Nutritional Service տ Recreationalտ Housing տ Senior Servicesտ Human Rights & Community Services տ Youth Services տ Juvenile & Adult Justice Services տ Other If you selected other, please tell us what function area best aligns with your organization: Please indicate three program goals/performance measures below. A few notes: x If you use percentages, please put the actual number equivalence. x Please ensure your performance measures are outcome based and not outputs. Program Goal # 1 Community Market will collect and purchase enough food items to provide groceries as often as once a month to member households. Performance Measure (How will you accomplish your goal?) # of households that receive food assistance Actual Results (Outcome) Ending FY2022 2,336 Projected Results (Outcome) Ending FY2023 3,200 Projected Results (Outcome) Ending FY2024 3,200 Program Goal # 2 A balanced, nutritionally dense meal will be served to any hungry person who shows up at meal times at the Community Kitchen and/or to residents at one of the shelters. DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Outside Agencies/Human Services Program information P a g e 2 3 o f 3 2 Performance Measure (How will you accomplish your goal?) # meals provided/food assistance Actual Results (Outcome) Ending FY2022 48,754 Projected Results (Outcome) Ending FY2023 54,000 Projected Results (Outcome) Ending FY2024 54,000 Program Goal # 3 Community Services program will provide emergency financial assistance and referral for essential needs, as applicable, to individuals by appointment. Performance Measure (How will you accomplish your goal?) # of individuals who receive emergency financial assistance for essential needs Actual Results (Outcome) Ending FY2022 1,253 Projected Results (Outcome) Ending FY2023 750 Projected Results (Outcome) Ending FY2024 750 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Exhibit B Emergency Assistance Scope of Services Federal Tax Id. or SSN 59-1224041 Contract # A. CONTRACTOR INFORMATION 1. Contractor Agency Name: Inter-Faith Council for Social Service, Inc. 2. If different from Contract Administrator Information in General Contract: Address Telephone Number: _ Fax Number: Email: 3. Name of Program (s): Emergency Assistance 4. Status: ( ) Public (X) Private, Not for Profit ( ) Private, For Profit 5. Contractor's Financial Reporting Year July 1, 2023 through June 30, 2024 B. Explanation of Services to be provided and to whom: Through the Emergency Assistance Program, the Contractor will assist eligible individuals with rent and related costs as well as Orange Water and Sewer Authority (OWASA) bills and related costs. The County will reimburse the Contractor up to $5,000/month, unless prior approval by County, for a total of $60,000 for the contract period for rent/related costs and/or Orange Water and Sewer Authority (OWASA) bills/related costs. To be eligible clients must: be residents of Orange County, have income at or below 200% of the Federal Poverty Level, and have a household experiencing a financial crisis. Payments are limited to $200 within a 12-month period. The County will also reimburse the Contractor for staff costs (including salary, FICA, and fringe) for administering the Emergency Assistance Program up to $25,000 for the contract period. The Contractor will submit program paperwork provided by County at time and dates designated by County. C. Funding reimbursement limits by category: Rent/related costs and OWASA bills/related costs $60,000 ($5,000 per month) Staff costs: salary, FICA, fringe $25,000 D. Number of units to be provided: NA E. Area to be served/Delivery site(s): Orange County Nancy Coston, Social Services Director (Signature of Contractor) _ (Date Submitted) (Date Submitted) 9 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 EXHIBIT “C” Scope of Services – FY 2023-2024 Outside Agency Performance Agreement Agency Name: Inter-Faith Council for Social Service Program Name: Food Programs Funding Award: $75,000 Outline how the agency will spend Orange County’s funding award. Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2024. • IFC's Community Kitchen serves hot meals daily to anyone who is hungry • IFC's Community Market (formerly Food Pantry) provides a full complement of groceries, personal care items and emergency financial assistance to prevent eviction and utility disruption. Anticipated Outcomes The Anticipated Results column must include quantifiable results in the form of number of persons/units served within Orange County, only (all Towns and municipalities). If you use percentages, you must also provide the total number of participants within that measure’s description or for an earlier performance measure. Performance Measures Anticipated Results % and # of households that receive food assistance (Market) 3,200 # meals provided/ food assistance (Kitchen) 54,000 % and # of individuals who receive emergency financial assistance for essential needs 750 Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) Expense Description Amount Personnel $60,750 Operations: Food Supplies, Kitchen Supplies, Utilities, Food $14,250 DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 Orange County Outside Agency Performance Agreement Page 10 of 10 Rev.04/23 ATTACHMENT “A” Orange County Certifications – FY 2023-24 Outside Agency Performance Agreement Chief Contact, Administrators, Chief Executive Officer and Chief Financial Officer I certify that I have provided a list of the chief contact, administrators, chief executive officer and chief financial officer for my agency with this Agreement and that I will keep it current to the County of Orange. The list should be in writing with the name, title, residential address; phone and email address and if possible, fax number. Officers and Board of Directors I certify that I have provided a current list of the Officers and Board of Directors with this Agreement and that we will continue to update the list as changes occur. The list should be in writing, with the name, physical address, mailing address and if possible, phone, fax and email address. Budget Submission I certify that I have provided a budget for the period to be covered by funding Orange County, and that any substantive changes made to this budget have been in advance authorized in writing by Orange County. Annual Financial Review I certify that I have provided a copy of the latest annual Financial Review for our agency and the budget adopted by the agency for the fiscal years encompassing this Agreement. If not, please explain on a separate sheet of paper. Alignment with Organization’s Mission I certify that the programs and services for which this funding is requested align with the mission of the organization. Intended Purpose I certify that the funds provided to the agency under the terms of this Agreement will be used for a public purpose and shall only be used for the purposes intended and any money not used for those purposes will be promptly returned to Orange County. Certified by: _______________________ Title: __________________________ Date: ___________ (Provider’s Signature) DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9 06/29/2023 Summers Insurance Group 2113 Cameron St., Suite 219 Raleigh NC 27605-1370 Megan Summers (919) 968-4472 megan.summers@relationinsurance.com Inter-Faith Council for Social Service, Inc. 110 W. Main Street Carrboro NC 27510 ANI - Alliance of Nonprofits for Ins 10023 Allied Eastern Indemnity Company 11242 ACE American Insurance Company 22667* CL2362970230 A Y 2023-17838 07/01/2023 07/01/2024 1,000,000 500,000 20,000 1,000,000 2,000,000 2,000,000 Annual Meeting A 2023-17838 07/01/2023 07/01/2024 1,000,000 Hired/borrowed A 10,000 2023-17838-UMB 07/01/2023 07/01/2024 1,000,000 1,000,000 B Y 0000583899 07/01/2023 07/01/2024 1,000,000 1,000,000 1,000,000 C Cyber Liability D97134637 03/01/2023 03/01/2024 Occurrence $1,000,000 Aggregate $1,000,000 Orange County, its officers, agents and employees are to be designated as "additional insured" with respect to the general liability insurance policy when required by written contract. Orange County, NC 300 West Tryon Street PO Box 8181 Hillsborough NC 27278 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY DocuSign Envelope ID: B72B9D20-BFE7-4847-8488-DC08B39534B9