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2023-462-E-Social Svc-Orange Congregations in Mission-outside agency funding & emergency assistance program
Orange Congregations in Mission Orange County Outside Agency Performance Agreement Revised 6/2018 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 Orange Congregations in Mission, a not-for-profit corporation, located at 300 Millstone Drive, Hillsborough, NC 27278 (“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 One Hundred and Three Thousand, Nine Hundred and Fifteen Dollars ($103,915). The County also agrees to appropriate funds for the provision of services described in Exhibit B, the maximum sum of Fifty One Thousand Dollars ($51,000). The total amounted appropriated by the County to Provider for these services shall be One Hundred Fifty Four Thousand, Nine Hundred and Fifteen Dollars ($154,915). 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: 876F9864-87DD-492C-B615-80555A87A4F0 2 i. For funds appropriated for Exhibit A services, the Provider shall be paid in four equal installments in the amount of $25,978.75. 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. The County will make an initial payment of $12,750 to Provider. The initial payment shall be used by Provider to pay for services as follows: $ 3,750 will be used to pay for staff costs and $9,000 will be used for reimbursement of client costs. Provider must provide documentation as provided in subsection ii below. Once Provider has provided documentation indicating that the initial payment has been expended then Provider shall submit documentation to County to be reimbursed for actual expenditures for all other 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 DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 3 time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or ii. In the event that Provider shall fail to render a satisfactory accounting as provided section 4 above, the County may terminate this Agreement and Provider shall return all payments already made to it by the County for services which have not been provided or for which no satisfactory accounting has been rendered; or iii. In the event of any fraudulent representation by the Provider in an invoice or other verification required to obtain payment under this Agreement or other dishonesty on a material matter relating to the performance of services under this Agreement. iv. Nonperformance, incomplete service or performance, or failure to satisfactorily perform any part of the work identified in the Scope of Services or to comply with any provision of this Agreement, as determined by the County in its sole discretion. v. Failure to adhere to the terms of applicable county, state or federal laws, regulations, or stated public policy. b. In the event of default by the Provider, the county may elect to terminate this Agreement, in whole or in part and/or require the Provider to repay the funds within ten (10) business days from written notice of default. The County may (but shall not be required to) grant the Provider an opportunity to cure the default without termination of this Agreement. This clause shall not be interpreted to limit the County’s remedies in law or in equity. 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; DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 4 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: 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, DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 5 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. 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 $ 16.60 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 Orange County Orange Congregations in Mission Department of Social Services 300 Millstone Drive Post Office Box 8181 Hillsborough, North Carolina 27278 Hillsborough, North Carolina 27278 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. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 6 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 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 _____________________________ _______________________ Rev. Sharon S. Freeland, Executive Director Date For and on behalf of Orange County Government _______________________________ ________________________ Bonnie Hammersley, County Manager Date DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 8/23/2023 8/28/2023 Revised 04/23 1 ORANGE COUNTY—INTERNAL USE ONLY ______________________________________________________________________________ Finance Information Vendor Name: Orange Congregations in Mission, Inc. Vendor Contact Person: Rev. Sharon S. Freeland Phone: 919-732-6194 Address: 300 Millstone Drive City Hillsborough State: NC Zip: 27278 Department: Social Services Amount: $154,915 Purpose: outside agency funding & emergency assistance program Budget Code(s): 10403020-630000 Vendor # 800010 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: 876F9864-87DD-492C-B615-80555A87A4F0 8/23/2023 8/24/2023 8/25/2023 8/28/2023 Orange County Outside Agency Performance Agreement Page 8 of 10 Rev.06/23 Exhibit A Provider’s Outside Agency Application DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Cover Page Page 6 of 31 COVER PAGE Applicant Contact Information Applicant Organization’s Legal Name: Orange Congregations in Mission Applicant Organization’s Physical Address: 300 Millstone Dr., Hillsborough, NC 27278 Applicant Organization’s Mailing Address: 300 Millstone Dr., Hillsborough, NC 27278 Applicant Organization’s Web Address: www.ocimnc.org Executive Director: Rev. Sharon S. Freeland Telephone Number: 919‐732‐6194 ex) 10 E‐Mail: ocim300mill@gmail.com Tax ID Number: 58‐1563438 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 Samaritan Relief Ministry Food, Client Rent/Utilities, Personnel 55,982.50 Meals on Wheels Food, Personnel 47,932.50 Totals 103,915 Briefly explain your proposed use of funds: To the best of my knowledge and belief all information and data in this application is true and current. The document has been duly authorized by the governing board of the applicant. Signature: Executive Director Date Signature: Orange County funds will be used for the Samaritan Relief Ministry to purchase food for the pantry, assist with client utility bills and, operating expenses for program manager salary and program assistant transition from part‐time to full‐time employment. For the Meals on Wheels program, the funds will be used for the catered meals and salary/mileage for program coordinator. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Cover Page Page 7 of 31 Board Chairperson Date Application Signatures: Please submit a wet signature or electronic signature, MS Word cursive fonts are not acceptable. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Cover Page Page 8 of 31 DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON‐DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates. YES NO a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? c) Current beneficiaries of the program for which funds are being requested? d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. NON‐DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti‐discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: Executive Director Date Signature: Board Chairperson Date Application Signatures: Please submit a wet signature or electronic signature, MS Word cursive fonts are not acceptable. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Program information P a g e 9 of 31 AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year): 05/1981 2. Agency’s Purpose/Mission (no more than a few sentences): To minister to the urgent needs of northern Orange County through the volunteer efforts of diverse congregations and individuals inspired by faith in God, and to enhance self‐sufficiency and awareness of community resources. 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). OCIM has provided food and financial assistance to Orange County residents in need for 41 years. The Orange County community continues to trust this agency to distribute their financial and in‐ kind donations compassionately and efficiently to the poor of northern Orange County. Required reports are submitted on time to Orange County and other donors such as United Way. 4. Living Wage: Does this agency pay permanent employees a minimum living wage? (Yes / No) yes If yes, is this agency an Orange County Living Wage Certified Employer? Yes If no, please briefly explain. Schedule of Positions: # of FTE – Full‐Time Paid Positions: 4 # of FTE – Part‐Time Paid Positions: 2.5 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? Statement of non‐discrimination: Orange Congregations in Mission will not discriminate against client services applicants, employees, providers, and volunteers, including board members or any other person or class of persons on the basis of race, gender, color, religion, sexual orientation, national origin, age, marital or veteran status, disability, or any other legally protected status. The board of directors discuss racial equity during their annual retreats. The Family Success Alliance was able to initially steer Latinx families to OCIM’s resources. These households are now informed about the services OCIM offers and seek assistance independently. 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). There are currently 50 congregations that make up Orange Congregations in Mission. These congregations encompass numerous denominations and faiths, and are racially diverse. Each congregation has a clergy member and two lay delegates who attend annual membership meetings where they vote on board members, budget, and by‐laws. The board of directors are nominated from the various congregations. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Program information P a g e 10 of 31 7. Please fill in your agency demographics in the table below: Agency Demographics Staff Board Gender Men 1 3 Women 6 2 Nonbinary/Genderqueer Self‐Describe Total 7 5 Race and Ethnicity Black or African‐American 5 3 American Indian or Alaska Native Asian Indian White 2 2 Native Hawaiian or Other Pacific Islander Chinese Japanese Vietnamese Filipino Korean Some other race Total 7 5 Of the above, how many Hispanic, Latino or Spanish origin 0 0 Of the above, how many non‐Hispanic, Latino or Spanish origin 0 0 Total 0 0 8. Please describe any activities your organization is doing to address racial equity. a. % of staff that have attended racial equity training: N/A b. % of board that have attended racial equity training: N/A c. Any additional activities: DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Program information P a g e 11 of 31 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 9. Program Name: Samaritan Relief Ministry Program Primary Contact and Title: Kay Stagner, Manager of Client Services Telephone Number: 919‐732‐6194 ex. 12 E‐Mail: ocimsrm@gmail.com 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) The Samaritan Relief Ministry provides groceries and financial assistance for rent, utilities, and prescription medication for people living in northern Orange County. This program aligns with Orange County’s Goal 1: Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well‐being of all county residents. The Samaritan Relief Ministry provides services to people living within the geographical boundaries of the Orange County School District. This area is primarily rural, with Hillsborough being the largest municipality. The Samaritan Relief Ministry food pantry is a referral‐based program. Various Orange County departments, school social workers, pastors, mental health programs, and local non‐profits make referrals for their clients who are in need of the services this program offers. 11. Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics SRM Projected 2022 Actual 2022 Projected 2023 Projected 2024 Gender INDIVIDUALS Men 2800 3191 3510 3510 Women 3500 3935 4330 4330 Nonbinary/Genderqueer Self‐Describe Total 6300 7126 7840 7840 Race and Ethnicity HOUSEHOLDS Black or African‐American 966 973 1114 1114 American Indian or Alaska Native Asian Indian White 1308 1402 1542 1542 Native Hawaiian or Other Pacific Islander DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Program information P a g e 12 of 31 Chinese Japanese Vietnamese Filipino Korean Unknown race 40 Total 2274 2415 2656 2656 Of the above, how many Hispanic, Latino or Spanish origin 289 216 238 238 Of the above, how many non‐Hispanic, Latino or Spanish origin 1985 2199 2418 2418 Total 2274 2415 2656 2656 Age INDIVIDUALS 0‐5 years 650 772 849 849 6‐17 years 1500 2033 2236 2236 18‐64 years 3900 4025 4428 4428 65+ years 250 296 327 327 Total 6300 7126 7840 7840 Geographic Location INDIVIDUALS Town of Chapel Hill Town of Carrboro Orange County (Outside of Chapel Hill/Carrboro) 6311 7126 7840 7840 Outside of Orange County Total 6311 7126 7840 7840 Income HOUSEHOLDS Low‐income (80% of the Area Median Income and Below) Please see income table in the attachments 2397 2656 2656 Total 2274 2397 2656 2656 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. SRM Actual 2021‐2022 Projected 2022‐2023 Projected 2023‐2024 Total Cost of Program 569,735 530,216 530,216 Total # of Individuals 7126 7840 7840 Cost Per Individual 79.95 67.63 67.63 DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Program information P a g e 13 of 31 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. 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. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Outside Agencies/Human Services Program information P a g e 14 of 31 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: ☐ Behavior Health ☐ Public Health & Health Education ☒ Food & Nutritional Service ☐ Recreational ☐ Housing ☐ Senior Services ☐ Human Rights & Community Services ☐ Youth Services ☐ Juvenile & Adult Justice Services ☐ 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: If you use percentages, please put the actual number equivalence. Please ensure your performance measures are outcome based and not outputs. Program Goal # 1 All eligible northern Orange County residents facing hunger are able to access emergency food. Performance Measure (How will you accomplish your goal?) # qualified/referred individuals will receive a week of groceries Actual Results (Outcome) Ending FY2022 5420 individuals received a week of food Projected Results (Outcome) Ending FY2023 5962 individuals will receive a week of food Projected Results (Outcome) Ending FY2024 5962 individuals will receive a week of food DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Outside Agencies/Human Services Program information P a g e 15 of 31 Program Goal # 2 Northern Orange County residents avoid eviction and utility shut-off Performance Measure (How will you accomplish your goal?) # households will receive financial assistance Actual Results (Outcome) Ending FY2022 613 households received financial assistance Projected Results (Outcome) Ending FY2023 674 households will receive financial assistance Projected Results (Outcome) Ending FY2024 674 households will receive financial assistance Program Goal # 3 Food pantry maintains adequate food supplies Performance Measure (How will you accomplish your goal?) # pounds of donated food will be received Actual Results (Outcome) Ending FY2022 183,451 pounds of donated food was received Projected Results (Outcome) Ending FY2023 200,000 pounds of food will be received Projected Results (Outcome) Ending FY2024 200,000 pounds of donated food will be received DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Outside Agencies/Human Services Program information P a g e 16 of 31 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 9. Program Name: Meals on Wheels Program Primary Contact and Title: Kay Stagner, Manager of Client Services Telephone Number: 919‐732‐6194 ex. 12 E‐Mail: ocimsrm@gmail.com 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) The Meals on Wheels program provides a nourishing, home delivered lunch, five days a week to homebound residents of northern Orange County. This program addresses Orange County’s goal 1: Ensure a community network of basic human services and infrastructure that maintains, protects, and promotes the well‐being of all county residents. While delivering lunch, volunteers are able to make a quick assessment of each recipient’s physical and cognitive condition; if there appears to be a change in condition, it is reported to the program coordinator who follows through with the recipient’s emergency contact or appropriate Orange County department, including Emergency Services. 11. Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics MOW Projected 2022 Actual 2022 Projected 2023 Projected 2024 Gender Men 26 24 26 26 Women 37 27 37 37 Nonbinary/Genderqueer Self‐Describe Total 63 53 63 63 Race and Ethnicity Black or African‐American 17 13 20 20 American Indian or Alaska Native Asian Indian White 46 40 43 43 Native Hawaiian or Other Pacific Islander Chinese Japanese Vietnamese Filipino DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Outside Agencies/Human Services Program information P a g e 17 of 31 Korean Some other race Total 63 53 63 63 Of the above, how many Hispanic, Latino or Spanish origin Of the above, how many non‐Hispanic, Latino or Spanish origin 63 53 63 63 Total 63 53 63 63 Age 0‐5 years 6‐18 years 18‐64 years 7 3 3 65+ years 56 53 60 60 Total 63 53 63 63 Geographic Location Town of Chapel Hill Town of Carrboro Orange County (Outside of Chapel Hill/Carrboro) 63 53 63 63 Outside of Orange County Total 63 53 63 63 Income Low‐income (80% of the Area Median Income and Below) Please see income table in the attachments 63 46 63 63 Total 63 46 63 63 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 $83,564 $63,525 $63,525 Total # of Individuals 53 63 63 Cost Per Individual $1,576.68 $1,008.33 $1,008.33 DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Outside Agencies/Human Services Program information P a g e 18 of 31 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: ☐ Behavior Health ☐ Public Health & Health Education ☒ Food & Nutritional Service ☐ Recreational ☐ Housing ☐ Senior Services ☐ Human Rights & Community Services ☐ Youth Services ☐ Juvenile & Adult Justice Services ☐ 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: If you use percentages, please put the actual number equivalence. Please ensure your performance measures are outcome based and not outputs. Program Goal # 1 Homebound seniors and disabled adults will improve nutrition and reduce social isolation Performance Measure (How will you accomplish your goal?) # Individuals will receive Meals on Wheels Actual Results (Outcome) Ending FY2022 53 individuals received Meals on Wheels Projected Results (Outcome) Ending FY2023 63 individuals will receive Meals on Wheels Projected Results (Outcome) Ending FY2024 63 individuals will receive Meals on Wheels DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Outside Agencies/Human Services Program information P a g e 19 of 31 Program Goal # 2 Homebound seniors and disabled adults will receive a home delivered meal Performance Measure (How will you accomplish your goal?) # Meals delivered Actual Results (Outcome) Ending FY2022 5782 meals were delivered Projected Results (Outcome) Ending FY2023 5800 meals will be delivered Projected Results (Outcome) Ending FY2024 5800 meals will be delivered Program Goal # 3 Volunteers will deliver Meals on Wheels Performance Measure (How will you accomplish your goal?) # volunteers scheduled Actual Results (Outcome) Ending FY2022 65 volunteers were scheduled Projected Results (Outcome) Ending FY2023 65 volunteers will be scheduled Projected Results (Outcome) Ending FY2024 65 volunteers will be scheduled DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Outside Agencies/Human Services Program information P a g e 20 of 31 Orange Congregations in Mission (OCIM) is requesting additional funding to grow the position of Samaritan Relief Ministry (SRM) Assistant from part‐time (27.5 hours a week, no benefits) to full‐time (40 hours a week with full benefits). The SRM currently has one full‐time employee (Manager of Client Services) and one part‐time employee (SRM Assistant). To be run most efficiently and to avoid gaps in coverage for clients, having at least two full‐time employees would be optimal. Orange County EA currently reimburses OCIM $15,000 annually for this part‐time position. An increase of an additional $10,000 is being requested to bring this position up to 40 hours a week. This increase would allow OCIM to provide health insurance and other benefits that are part of the full‐time benefit package. OCIM has a very low turn‐over rate for its full‐time employees. The average longevity for the four full‐time employees is about 24 years. We would like to retain the excellent employee we currently have and feel the best way would be to offer a competitive wage and desirable benefits. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Program information P a g e 23 of 31 Community Impact Award If you are applying for the Town of Chapel Hill’s Community Impact Award, please provide responses to the questions below. All other applicants, please skip these questions. (Responses should not exceed 100 words per question) 1. Please describe the impact the proposed programs will have on the target population. Please include specific quantitative and qualitative data in your response. 2. What methods/tools will your organization use to evaluate the proposed program’s effectiveness? Please include specific examples, such as a logic model. 3. Please briefly describe how your proposed programs aligns with evidence‐based approaches to addressing human service need(s). 4. Please describe one to three key partnerships/collaborations that add the most value to the success of the proposed programs. 5. If you are not awarded a Community Impact Award, what would your agency’s funding request be? DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Attachments Page 24 of 31 4. ATTACHMENTS Description of Required Attachments a) Financial Audit A recent financial audit that should cover CY2021, for calendar year agencies, and FY2021‐2022, for fiscal year agencies. For agencies with prior year revenues totaling $500,000 or more a financial audit, prepared by a certified public accountant is required. Agencies with prior year revenues of less than $500,000 may submit a completed Schedule of Receipts and Expenditures form (see application materials), in lieu of an audit/report. Agencies with a certified audit/report should not complete the form. Schedule of Receipts and Expenditures form is listed on the Town’s and county website here. b) Agency Budget Please complete the provided template or submit your own budget file (as long as it contains the same information, and in a similar format, as requested in the provided template. Please explain other in your budget). Agency Budget Template is listed on the Town’s and County website here. Please submit In PDF form only. c) Program Budget You may complete the provided template, or you may submit your own budget file (as long as it contains the same information, in the same format, as requested in the provided template. Please explain other in your budget). Program Budget Template is listed on the Town’s and County website here. Please submit in pdf only. d) IRS Federal Form 990 A copy of the agency’s 2020 Form 990 is required. The specific form depends upon the agency’s financial activity. Review the IRS’ table guide, for more details. For Form 990‐N (e‐postcard) filers, include a copy of the postcard, with the agency’s application materials. e) NC Solicitation License A copy of the agency’s current solicitation license is required. Organizations that solicit contributions in North Carolina, directly or through a third party, must renew their licenses annually. For more details, refer to the NC Secretary of State’s licensing website and its Frequently Asked Questions Guide (PDF), about exemptions. If exempt per N.C.G.S. § 131F‐3, include a copy of the exemption letter with the agency’s application materials. f) IRS Federal Tax‐Exemption Letter A copy of the agency’s current IRS tax‐exempt letter that confirms its nonprofit status is required. An agency can request a copy of its letter from the IRS’ Customer Account Services. g) List of Board of Directors Provide the following information about each board of director’s member: name, telephone number, address, occupation or affiliation of each member and the list must identify the principal officers of the governing body, and length of term. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Attachments Page 25 of 31 h) Certificate of Liability Insurance A copy of the agency’s current certificate, from the agency’s insurance carrier. Table 1 below outlines insurance types and minimums required, for each jurisdiction. If exempt from Worker’s Compensation compliance, include a statement explaining why, with the agency’s application materials. NOTE: Proof of insurance is not required at the time of application submission. If your agency is approved for funding, documentation of insurance must be provided to the jurisdiction awarding the funding when the contract is awarded. The insurance certificate should reflect the funding jurisdiction as an additional insured party and certificate holder and provide coverage for the duration of the funding period (July 1 – June 30). Renewal certificates must be sent to the jurisdiction 30 days prior to any expiration date, cancellation or modification of any stipulated insurance coverage. NOTE: Upon request, insurance requirements may be reviewed on a case by case basis by the Town or County. Please contact the staff identified on the Submission Requirements on Page 2 if you have questions or would like to request a review of your insurance requirements. Table 1. Forms of Liability Insurance and Minimum Policy Amounts Required INSURANCE TOWN OF CARRBORO TOWN OF CHAPEL HILL ORANGE COUNTY3 Worker's Compensation1 Limits for Coverage A ‐ Statutory State NC, for each employee Limits for Coverage B ‐ Employers Liability of: $1 million Each Occurrence $1,000,000 BID2 limit Limits for Coverage A ‐ Statutory State NC, for each employee Limits for Coverage B ‐ Employers Liability of: $1,000,000 Each Occurrence $1,000,000 BID for each employee $1,000,000 BID policy limit The contractor shall provide and maintain, during the life of the contract, workers’ compensation insurance as required by law, as well as employer’s liability coverage as noted below. Employer’s Liability: Workers’ Compensation is required if the contractor/vendor has employees. Owner Waiver is acceptable for a Sole Proprietor. Limits for Coverage A ‐ Statutory State NC, for each employee Limits for Coverage B ‐ Employers Liability of: $1 million Each Occurrence $1,000,000 BID2 limit Commercial General Liability $1 million Each Occurrence $2 million Aggregate $1 million Each Occurrence $2 million Aggregate $1 million Each Occurrence $2 million Aggregate DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Attachments Page 26 of 31 Products/Completed Operations, Explosion, Collapse & Underground Automobile Liability $1 million Each Occurrence *Only required for agencies doing travel as part of the agreement with the Town. $1 million Each Occurrence *Owned/non‐owned, and hired motor vehicle $1 million Each Occurrence *Only required for agencies doing travel as part of the agreement with the County. Professional Liability $1 million Each Occurrence $2 million Aggregate $1 million Each Occurrence $2 million Aggregate $1 million Each Occurrence $2 million Aggregate Sexual Abuse & Molestation $1 million Each Occurrence $2 million Aggregate *Only required for agencies doing direct work with minors (under the age of 18). $1 million Each Occurrence $2 million Aggregate *May be required for contractors working directly one‐on‐ one with children and elderly or in overnight sheltering capacities. $1 million Each Occurrence $2 million Aggregate *Only required for agencies doing direct work with minors (under the age of 18). Cyber Liability $1 million Each Occurrence $2 million Aggregate *Only required for agencies transmitting personal identifiable information that is disseminated electronically $1 million Each Occurrence $2 million Aggregate *May be required for Contractors having access to personal identifying information, and/or computer networks. $1 million Each Occurrence $2 million Aggregate *Only required for agencies transmitting personal identifiable information that is disseminated electronically. Visit the NC Industrial Commission’s website for more information regarding Coverage A. Also, note that if an agency uses subcontractors, it must require subcontractors to have workmen’s compensation insurance. Bodily Injury by Disease (BID). Please visit Orange County’s Risk Management page for more information about the County’s Minimum Insurance Requirements. For additional information regarding the Town of Chapel Hill’s Minimum Insurance Requirements, please contact the Office of Risk Management or Business Management. Town of Chapel Hill At‐your‐Service. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Attachments Page 27 of 31 2022 Income Limits US Department of Housing and Urban Development (HUD) Durham‐Chapel Hill Metropolitan Statistical Area (Durham, Orange, and Chatham Counties) Income Level 1 person 2 people 3 people 4 people 5 people 6 people 7 people 8 people 30% area median income $20,100 $22,950 $25,800 $28,650 $32,470 $37,190 $41,910 $46,630 50% area median income $33,450 $38,200 $43,000 $47,750 $51,600 $55,400 $59,250 $63,050 60% area median income $40,150 $45,850 $51,600 $57,300 $61,900 $66,500 $71,100 $75,650 80% area median income $53,500 $61,150 $68,800 $76,400 $82,550 $88,650 $94,750 $100,850 DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Prepared by the Town of Chapel Hill Office for Housing and Community Approved by the Chapel Hill Town Council June 20, 2018 and the Town of Carrboro Board of Alderman October 23, 2018 Attachments Human Services Program Results Framework The Town of Chapel Hill and the Town of Carrboro’s Human Services Program funds programs that improve education, livelihood security, and health outcomes for all residents. The program’s overarching goal is to achieve economic and social wellbeing and opportunities to thrive for all residents, particularly those who are low‐income or otherwise disenfranchised. Goal: All Chapel Hill and Carrboro residents experience economic and social well‐being & opportunities to thrive. Strategic Objective 1: Children improve their education outcomes Strategic Objective 2: Residents increase their livelihoods security Strategic Objective 3: Residents improve their health outcomes Intermediate Result 1.1: Children birth‐to‐K access early childhood development opportunities Intermediate Result 1.2: Children demonstrate new grade‐level‐appropriate skills Intermediate Result 2.1: Residents access the most appropriate social safety net services Intermediate Result 2.2: Residents increase job skills appropriate for the local economy Intermediate Result 3.1: Residents access basic health care services (primary, behavioral, dental) Intermediate Result 3.2: Residents demonstrate new healthy lifestyle behaviors DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Attachments Strategic Objective 1: Children improve their education outcomes Intermediate Result 1.1: Children birth‐to‐K access early childhood development opportunities Agency Performance Indicators % and # of children receiving scholarships who attend licensed, 4‐5‐star childcare facilities % and # of program participant children who are read age‐appropriate books in their home once a week % and # of children referred to socio‐emotional health services that complete an age appropriate therapeutic or enrichment program Intermediate Result 1.2: Children demonstrate new grade‐level‐appropriate skills (grades K‐12) Agency Performance Indicators % and # of program participants that are promoted to the next grade % and # of program participants that improve grades by end of program period % and # of program participants that improve classroom behavior % and # of program participants that express greater confidence in their ability to be successful at school % and # of program participants that express greater confidence in their leadership and pro‐ social abilities % and # of children referred to socio‐emotional health services that complete an age appropriate therapeutic or enrichment program % and # of program participants who plan on attending post‐secondary education Strategic Objective 2: Residents increase their livelihoods security Intermediate Result 2.1: Residents access the most appropriate social safety net services Agency Performance Indicators % and # of program participants with knowledge of appropriate social services % and # of completed referrals % and # Client satisfaction rates % and # of program participants who meet at least 1 financial goal % and # of program participants who maintain or improve their housing status % and # of unduplicated community members who receive emergency shelter services % and # of program participants who are homeless or experiencing unstable housing who obtain housing % and # of individuals that receive abuse and neglect prevention and response services % and # of program participants that receive food assistance % and # of individuals who receive emergency financial assistance for essential needs % and # of individuals who receive legal information, services or referral % and # of participants who do not become court involved during the program Intermediate Result 2.2: Residents increase job skills appropriate for the local economy Agency Performance Indicators % and # of participants who pass ESL tests % and # of participants who self‐report improved English language abilities % and # of participants who earn GEDs DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Attachments % and # of program participants who secure employment % and # of program participants who report improved wages and benefits % and # of program participants who report that services enabled employment, education or training % and # of participants who increase incomes (wages, disability, public benefits, or other income) % and # of participants who maintain incomes (wages, disability, public benefits, or other income) Strategic Objective 3: Residents improve their health outcomes Intermediate Result 3.1: Residents access basic health care services (primary, behavioral, dental) Agency Performance Indicators % and # of program participants that report they have access to primary care % and # of program participants that report they have access to behavioral care % and # of program participants that report they have access to dental care % and # of program participants who report they have improved access to health care services % and # of preventive screenings provided % and # of individuals referred to health promotion and/or healthcare services % and # of program participants that report they have access to substance abuse treatment Intermediate Result 3.2: Residents demonstrate new healthy lifestyle behaviors Agency Performance Indicators # of people reporting healthier functionality and lifestyle behaviors (improved nutrition, conflict resolution skills, stress reduction practices, exercise at least 30min 3x a week, annual check‐ups, etc.) % and # of program participants who demonstrate new physical skills that support their independence % and # of program participants who demonstrate new, improved, or restored social skills % and # of program participants who demonstrate new, improved, or restored life skills % and # of program participants who report new, improved, or restored social connections % and # of program participants who meet one wellness goal % and # of program participants who comply with treatment % and # of hospitalization rates among program participants with substance abuse and/or psychiatric disorders % and # of program participants that consume fresh food Other Measures Total residents served % and # of agencies that pay employees a living wage % and # of agencies that offer health benefits to employees DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 Attachments Key Terms Goal: The longer‐term, wider change to which the program contributes. Strategic Objective (SO): The benefit expected to occur for beneficiary groups. SOs express the central purpose of the program in a realistic, specific, measurable way. Intermediate Result (IR): The expected change in identifiable behaviors of a specific group or the expected change in systems, policies or institutions required to achieve the strategic objectives. Output: The goods, services, knowledge, skills, attitudes and enabling environment that are delivered by the project (as a result of the activities undertaken). Indicators: Quantitative or qualitative factors or variables that provide a simple and reliable means to measure achievement, to reflect the changes connected to an intervention, or to help assess the performance of a development actor. Performance indicator statements should be SMART (specific, measurable, achievable, relevant, time bound). Measurement In a results framework, results statements are measured through performance indicators. Agency performance indicators will be measured and reported on annually by funded agencies. The Human Services Program will report on the overall results. During the first year of implementation of the results framework, staff will determine the appropriate frequency of measurement and reporting. We anticipate being able to disaggregate measures by gender, race, ethnicity, age, and disability status. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 9 Exhibit B Emergency Assistance Scope of Services Federal Tax Id. or SSN ____58-1563438____________ Contract # ________________ A. CONTRACTOR INFORMATION 1. Contractor Agency Name: Orange Congregations in Mission 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 Town of Hillsborough water bills and related costs. The County will reimburse the Contractor up to $3,000/month, unless prior approval by County, for a total of $36,000for the contract period for rent/related costs and/or Town of Hillsborough 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 $15,000 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 Town of Hillsborough bills/related costs $36,000 ($3,000per month) Staff costs: salary, FICA, fringe $15,000 D. Number of units to be provided: NA E. Details of Billing process and Time Frames: One fourth of the contract amount ($9,000 for rent and related costs and $3,750 for staff costs) for Emergency Assistance services described in this contract will be paid upon receipt of a completed contract. The Contractor will subsequently provide payment records for actual costs for the initial payment. After payment records are provided for the entire initial payment, the County will reimburse the Contractor for services described in this contract up to the budgetary limits of the contract allotment. The County will reimburse the Contractor for actual expenditures for approved services provided. For reimbursement, the Contractor must submit copies of bills, checks, receipts and/or other proof of expenditures by the fifth of the month for the preceding month’s expenditures to the designated County Administrator. The Contractor must submit a payment records for staff cost reimbursement. The County will reimburse the Contractor monthly upon receipt of a complete and correctly filed report. DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 10 F. Area to be served/Delivery site(s): __Orange County ___________ ____________________________________ _____ _____ _____________ Nancy Coston, Social Services Director (Signature of Contractor) _ ___________ _____________ (Date Submitted) (Date Submitted) DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 EXHIBIT “C” Scope of Services – FY 2023-2024 Outside Agency Performance Agreement Agency Name: Orange Congregations in Mission, Inc. Program Name: Samaritan Relief Ministry Funding Award: $55,982.50 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. • Provide a week’s worth of groceries to referred households. • Provide emergency financial assistance for rent and utilities. 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 Number of meals/grocery services provided to qualifying households 6,393 Number of qualifying households receiving emergency financial assistance for rent and utilities 154 Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) Expense Description Amount Personnel-program manager salary $29,982.50 Rent and utility assistance $15,000 Food $11,000 DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 EXHIBIT “C” Scope of Services – FY 2023-2024 Outside Agency Performance Agreement Agency Name: Orange Congregations in Mission, Inc. Program Name: Meals on Wheels Funding Award: $47,932.50 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. • Delivery of meals to elderly/disabled residents five days/week (Monday-Friday). • Recruit and retain ample volunteers to meet the delivery needs of the program. • Follow-up on all service inquiries, interview potential recipients, assign qualified individuals to existing Meals on Wheels routes. 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 Number of meals delivered 9,500 Number of new direct interviews conducted and/or individuals enrolled in program 20 Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) Expense Description Amount Meals on Wheels meal purchases $27,825 Personnel- salary and mileage to support programming $20,107.50 DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0 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: 876F9864-87DD-492C-B615-80555A87A4F0 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 8/15/2023 High &Rubish Insurance PO Box 3040 Chapel Hill NC 27515-3040 Laura Pope 919-913-1144 919-913-1155 Laura@highandrubish.com License#:1000008811 Cincinnati Insurance Companies 10677 OCIMINC-01 USLI 25895OCIM,Inc. Orange Congregations in Mission 300 Millstone Dr. Hillsborough NC 27278 Hartford Underwriters Ins.30104 162602941 A X 2,000,000 X 2,000,000 10,000 2,000,000 4,000,000 X Y Y ECP 0349072 10/15/2021 10/15/2024 4,000,000 A 2,000,000 X X EBA 0349072 10/15/2022 10/15/2023 C 22WECBV6360 8/18/2023 8/18/2024 100,000 100,000 500,000 B D&O NDO1043382L 7/21/2023 7/21/2024 D&O 1,000,000 Orange County PO Box 8181 300 W.Tryon St Hillsborough NC 27278 USA DocuSign Envelope ID: 876F9864-87DD-492C-B615-80555A87A4F0