HomeMy WebLinkAbout2023-492-E-Housing Dept-Amendment-ESG FY22 rapid rehousingNCDHHS ACT2007 (Amendment Template) (Rev. 11.01.15)
AMENDMENT
This Agreement amends the contract bearing the effective date of 1/1/2023 between the North Carolina
Department of Health and Human Services, Division of Aging and Adult Services, hereinafter referred to
as the "Division" and Orange County Dept. of Housing & Community Develop, hereinafter referred to as
the "Contractor." This Amendment is hereby effective on 8/14/2023.
As provided for under the terms of this contract, the Division and the Contractor agree to amend the
following contract provisions:
1.Reference “Effective Period”: The termination date of 12/31/2023 has not changed
2.Reference “Contractor’s Duties”: The Contractor shall provide the amended services as
described in the scope of work.
3.Reference “Division’s Duties”: The total amount paid by the Division to the Contractor is being
increased by $4,070 from $40,704 to $44,774. This amended amount consists of $0 in State
funds, $0 in Local funds, $0 in Other funds and $4,070 in Federal funds.
The Contractor’s matching requirement for this amendment is $0. The total contractor's matching amount
is $0.
The total amendment amount is $4,070.
The total contract amount is $44,774.
All other terms and conditions as set forth in the original contract document shall remain in effect for the
duration of this Agreement.
Signatures follow on next page
Contract Number 00045330, Amendment Number 1 / Page 1 of 15
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NCDHHS ACT2007 (Amendment Template) (Rev. 11.01.15)
In Witness Whereof, the Contractor and the Division have executed this contract in duplicate originals,
with one original being retained by each party.
Orange County Dept. of Housing & Community Develop
Signature Date
Bonnie Hammersley County Manager
Printed Name Title
Division of Aging and Adult Services, North Carolina Department of Health and Human Services
Authorized Signature Date
Printed Name Title
Contract Number 00045330, Amendment Number 1 / Page 2 of 15
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9/18/2023
Scope of Work (Rev. 06/11)
SCOPE OF WORK
PURPOSE
The purpose of this amendment is to add funds for administration costs. There are no
changes to the scope of work. Performance measures and budget have been updated.
Contract Number 00045330, Amendment Number 1 / Page 3 of 15
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Performance Measures (Rev. 4//12)
PERFORMANCE MEASURES CHART
The Department of Health and Human Services uses performance measures rubrics as a tool to
determine the success of a project and how well services and products are being delivered.
Together they enable the Department to gauge efficiency, determine progress toward desired
results and assess whether the Department is on track with meeting its goals. The contractor
shall adhere to all of the performance requirements/standards in the scope of work, including
performance measures in the performance measures chart below.
Measure
Type
Input Reporting
Frequency
Quarterly
Measure All subrecipients must submit 1 requisition per month within the 45-day submission
period with a minimum of 1 requisition per quarter leading to a disbursement of
funds.
Budget Year 1 Trend Increase
Baseline
Value
$44,774
Target Value 100% of the allocation by the end of the contract period
Data Source fiscal data monitoring and requests for reimbursement
Collection
Process and
Calculation
reimbursement submission
Collection
Frequency
monthly
Measure
Type
Output Reporting
Frequency
Monthly
Measure 80% of requisitions submitted were correctly submitted
Budget Year 1 Trend Increase
Baseline
Value
0
Target Value 80% of submissions
Data Source fiscal data monitoring
Collection
Process and
reimbursement submission
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Performance Measures (Rev. 4//12)
Calculation
Collection
Frequency
monthly
Measure
Type
Outcome Reporting
Frequency
Annual
Measure Program Compliance- On-site or virtual desk monitoring by the ESG office yields
10% or less findings/concerns in cumulative records reviewed.
Budget Year 1 Trend Increase
Baseline
Value
0
Target Value 90%
Data Source electronic submission and file submission
Collection
Process and
Calculation
onsite, virtual and/or desk monitoring
Collection
Frequency
Monthly and quarterly
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Line Item Budget Detail (08/11)
LINE ITEM BUDGET
This begins the line item budget for year 1
Budget Detail - Year 1
Category Item Narrative Original Amount Change Amount Final Amount
Salary\Wages $0.00 $0.00 $0.00
Fringe Benefits $0.00 $0.00 $0.00
Other $0.00 $0.00 $0.00
Repair and Maintenance $0.00 $0.00 $0.00
Staff Development $0.00 $0.00 $0.00
Dues and Subscriptions $0.00 $0.00 $0.00
Operational Other Not
Otherwise
Classified
RRH Services: Rapid Re-housing services
include housing search and placement,
housing stability case management,
landlord-tenant mediation, tenant legal
services, credit repair
$40,704.00 $0.00 $40,704.00
Operational Other Not
Otherwise
Classified
Administration $0.00 $4,070.00 $4,070.00
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Line Item Budget Detail (08/11)
Budget Detail - Year 1
Category Item Narrative Original Amount Change Amount Final Amount
Subcontracts and Grants $0.00 $0.00 $0.00
Match $0.00 $0.00 $0.00
Cost Per Service $0.00 $0.00 $0.00
Sub Total $40,704.00 $4,070.00 $44,774.00
Indirect Cost $0.00 $0.00 $0.00
Total Budget $40,704.00 $4,070.00 $44,774.00
Subcontracting and Grants Budget Detail - Year 1
Category Item Narrative Original Amount Change Amount Final Amount
$0.00 $0.00 $0.00
Sub Total $0.00 $0.00 $0.00
Salaries - Year 1
Persons Position or Title Annual Salary Hourly
Rate
Months Work %Fringe
Amount Total
Fringe
Percent Total
Total
0 $0.00 0.0000 0 0%$0.00 $0.00 $0.00
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Line Item Budget Detail (08/11)
Contract Number 00045330, Amendment Number 1 / Page 8 of 15
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FEDERAL CERTIFICATIONS
The undersigned states that:
1. He or she is the duly authorized representative of the Contractor named below;
2. He or she is authorized to make, and does hereby make, the following certifications on behalf of the Contractor, as set
out herein:
a. The Certification Regarding Nondiscrimination;
b. The Certification Regarding Drug-Free Workplace Requirements;
c. The Certification Regarding Environmental Tobacco Smoke;
d. The Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier Covered
Transactions; and
e. The Certification Regarding Lobbying;
3. He or she has completed the Certification Regarding Drug-Free Workplace Requirements by providing the addresses
at which the contract work will be performed;
4. [Check the applicable statement]
[ ] He or she has completed the attached Disclosure Of Lobbying Activities because the Contractor has made,
or has an agreement to make, a payment to a lobbying entity for influencing or attempting to influen ce an officer
or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a
Member of Congress in connection with a covered Federal action;
OR
[X ] He or she has not completed the attached Disclosure Of Lobbying Activities because the Contractor has not
made, and has no agreement to make, any payment to any lobbying entity for influencing or attempting to
influence any officer or employee of any agency, any Member of Congress, any officer or employee of Congress,
or any employee of a Member of Congress in connection with a covered Federal action.
5. The Contractor shall require its subcontractors, if any, to make the same certifications and disclosure.
________________________________________________________________________________________________
Signature Title
________________________________________________________________________________________________
Contractor Name Date
[This Certification Must be Signed by the Same Individual Who Signed the Proposal Execution Page]
I. Certification Regarding Nondiscrimination
The Contractor certifies that it will comply with all Federal statutes relating to nondiscrimination. These include but are
not limited to: (a) Title VI of the Civil Rights Act of 1964 (P.L. 88 -352) which prohibits discrimination on the basis of race,
color or national origin; (b) Title IX of the Education Amendments of 1972, as amended (20 U.S.C. §§1681 -1683, and
1685-1686), which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as
amended (29 U.S.C. §794), which prohibits discrimination on the basis of handicaps; (d) the Age Discrimination Act of
1975, as amended (42 U.S.C. §§6101-6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office
and Treatment Act of 1972 (P.L. 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; (f) the
Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (P.L. 91 -616), as
amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; (g) Title VIII of the Civil Rights Act of
1968 (42 U.S.C. §§3601 et seq.), as amended, relating to nondiscrimination in the sale, re ntal or financing of housing; (h)
the Food Stamp Act and USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i)
the requirements of any other nondiscrimination statutes which may apply to this Agreement.
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12/2/2022
County Manager
Bonnie Hammersley
Contract Number 00045330, Amendment Number 1 / Page 9 of 15
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II. Certification Regarding Drug-Free Workplace Requirements
1. The Contractor certifies that it will provide a drug-free workplace by:
a. Publishing a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession or
use of a controlled substance is prohibited in the Contractor’s workplace and specifying the actions that will be
taken against employees for violation of such prohibition;
b. Establishing a drug-free awareness program to inform employees about:
i. The dangers of drug abuse in the workplace;
ii. The Contractor’s policy of maintaining a drug-free workplace;
iii. Any available drug counseling, rehabilitation, and employee assistance programs; and
iv. The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace;
c. Making it a requirement that each employee be engaged in the performance of the agreement be given a copy of
the statement required by paragraph (a);
d. Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the
agreement, the employee will:
i. Abide by the terms of the statement; and
ii. Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later
than five days after such conviction;
e. Notifying the Department within ten days after receiving notice under subparagraph (d)(ii) from an employee or
otherwise receiving actual notice of such conviction;
f. Taking one of the following actions, within 30 days of receiving notice under subparagraph (d)(ii), with respect to
any employee who is so convicted:
i. Taking appropriate personnel action against such an employee, up to and including
termination; or
ii. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program
approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate
agency; and
g. Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs
(a), (b), (c), (d), (e), and (f).
2. The sites for the performance of work done in connection with the specific agreement are listed below (list all sites;
add additional pages if necessary):
Address
Street 300 W Tryon St.
________________________________________________________________________________________________
City, State, Zip Code Hillsborough, NC, 27278
________________________________________________________________________________________________
Street
________________________________________________________________________________________________
City, State, Zip Code
________________________________________________________________________________________________
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3. Contractor will inform the Department of any additional sites for performance of work under this agreement.
4. False certification or violation of the certification may be grounds for suspension of payment, suspension or
termination of grants, or government-wide Federal suspension or debarment. 45 C.F.R. 82.510.
III. Certification Regarding Environmental Tobacco Smoke
Public Law 103-227, Part C-Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act), requires
that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used
routinely or regularly for the provision of health, day car e, education, or library services to children under the age of 18, if
the services are funded by Federal programs either directly or through State or local governments, by Federal grant,
contract, loan, or loan guarantee. The law does not apply to children 's services provided in private residences, facilities
funded solely by Medicare or Medicaid funds, and portions of facilities used for inpatient drug or alcohol treatment. Failure
to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $1,000.00 per day
and/or the imposition of an administrative compliance order on the responsible entity.
The Contractor certifies that it will comply with the requirements of the Act. The Contractor further agrees that it will
require the language of this certification be included in any subawards that contain provisions for children's services and
that all subgrantees shall certify accordingly.
IV. Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions
Instructions
[The phrase "prospective lower tier participant" means the Contractor.]
1. By signing and submitting this document, the prospective lower tier participant is providing the certification set out
below.
2. The certification in this clause is a material representation of the fact upon which reliance was placed when this
transaction was entered into. If it is later determined that the prospective lower tier participant knowingly rendered an
erroneous certification, in addition to other remedies available to the Federal Government, the department or agency
with which this transaction originate may pursue available remedies, including suspension and/or debarment.
3. The prospective lower tier participant will provide immediate written notice to the person to whom this proposal is
submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted
or has become erroneous by reason of changed circumstances.
4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant,"
"person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded," as used in this clause, have
the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549, 45 CFR
Part 76. You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those
regulations.
5. The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered
transaction be entered into, it shall not knowingly enter any lower tier covered transaction with a person who is
debarred, suspended, determined ineligible or voluntarily exc luded from participation in this covered transaction
unless authorized by the department or agency with which this transaction originated.
6. The prospective lower tier participant further agrees by submitting this document that it will include the clause ti tled
"Certification Regarding Debarment, Suspension, Ineligibility and Voluntary Exclusion --Lower Tier Covered
Transaction," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered
transactions.
7. A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered
transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from covered transaction, unless it
knows that the certification is erroneous. A participant may decide the method and frequency by which it determines
the eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List.
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8. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to
render in good faith the certification required by this clause. The knowledge and information of a participant is not
required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
9. Except for transactions authorized in paragraph 5 of these instructions, if a participant in a covered transaction
knowingly enters into a lower tier covered transaction with a person who is suspended, debarred , ineligible, or
voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal
Government, the department or agency with which this transaction originated may pursue available remedies,
including suspension, and/or debarment.
Certification
1. The prospective lower tier participant certifies, by submission of this document, that neither it nor its principals is
presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily exclu ded from participation
in this transaction by any Federal department or agency.
2. Where the prospective lower tier participant is unable to certify to any of the statements in this certification, such
prospective participant shall attach an explanation to this proposal.
V. Certification Regarding Lobbying
The Contractor certifies, to the best of his or her knowledge and belief, that:
1. No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal
contract, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative
agreement.
2. If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any age ncy, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with this Federally funded contract, grant, loan, or
cooperative agreement, the undersigned shall complete and submit Standard Form SF -LLL, "Disclosure of Lobbying
Activities," in accordance with its instructions.
3. The undersigned shall require that the language of this certification be included in the award document for subawards
at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) who
receive federal funds of $100,000.00 or more and that all subrecipients shall certify and disclose accordingly.
4. This certification is a material representation of fact upon which reliance was placed whe n this transaction was made
or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by
Section 1352, Title 31, U.S. Code. Any person who fails to file the required certification shall be subj ect to a civil
penalty of not less than $10,000.00 and not more than $100,000.00 for each such failure.
VI. Disclosure Of Lobbying Activities
Instructions
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Fe deral recipient, at the
initiation or receipt of a covered Federal action, or a material change to a previous filing, pursuant to title 31 U.S.C. sec tion
1352. The filing of a form is required for each payment or agreement to make payment to any lobbying entity for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or
employee of Congress, or an employee of a Member of Congress in connection with a covered Federal action. Use the
SF-LLL-A Continuation Sheet for additional information if the space on the form is inadequate. Complete all items that
apply for both the initial filing and material change report. Refer to the implementing guidance published by the Office of
Management and Budget for additional information.
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Identify the type of covered Federal action for which lobbying activity is and/or has been secured to influence the outcome
of a covered Federal action.
1. Identify the status of the covered Federal action.
2. Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the
information previously reported, enter the year and quarter in which the change occurred. Enter the date of the last
previously submitted report by this reporting entity for this covered Federal action.
3. Enter the full name, address, city, state and zip code of the reporting entity. Include Congressional District, if known.
Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or sub-
award recipient. Identify the tier of the subawardee, e.g., the first subawardee of the prime is the 1st tier. Subawards
include but are not limited to subcontracts, subgrants and contract awards under grants.
4. If the organization filing the report in Item 4 checks "Subawardee", then enter the full name, address, city, state and
zip code of the prime Federal recipient. Include Congressional District, if known.
5. Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational
level below agency name, if known. For example, Department of Transportation, United States Coast Guard.
6. Enter the Federal program name or description for the covered Federal action (Item 1). If known, enter the full
Catalog of Federal Domestic Assistance (CFDA) number for grants, cooperative agreements, loans, and loan
commitments.
7. Enter the most appropriate Federal Identifying number available for the Federal action identified in Item 1 (e.g.,
Request for Proposal (RFP) number, Invitation for Bid (IFB) number, grant announcement number, the contract grant,
or loan award number, the application/proposal control number assigned by the Federal agency). Include prefixes,
e.g., "RFP-DE-90-001."
8. For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the
Federal amount of the award/loan commitment for the prime entity identified in Item 4 or 5.
9. (a) Enter the full name, address, city, state and zip code of the lobbying entity engaged by the reporting entity
identified in Item 4 to influence the covered Federal action.
(b) Enter the full names of the individual(s) performing services, and include full address if different from 10(a). Enter Last
Name, First Name and Middle Initial (MI).
10. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity (Item 4) to the
lobbying entity (Item 10). Indicate whether the payment has been made (actual) or will be made (planned). Check all
boxes that apply. If this is a material change report, enter the cumulative amount of payment made or planned to be
made.
11. Check the appropriate boxes. Check all boxes that apply. If payment is made through an in -kind contribution, specify
the nature and value of the in-kind payment.
12. Check the appropriate boxes. Check all boxes that apply. If other, specify nature.
13. Provide a specific and detailed description of the services that the lobbyist has performed, or will be expected to
perform, and the date(s) of any services rendered. Include all preparatory and related activity, not just time spent in
actual contact with Federal officials. Identify the Federal official(s) or employee(s) contacted or the officer(s),
employee(s), or Member(s) of Congress that were contacted.
14. Check whether or not a SF-LLL-A Continuation Sheet(s) is attached.
15. The certifying official shall sign and date the form, print his/her name, title, and telephone number.
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. Send comments regarding the burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden, to the Office of Management and
Budget, Paperwork Reduction Project (0348-0046), Washington, D. C. 20503
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Disclosure Of Lobbying Activities
(Approved by OMB 0344-0046)
Complete this form to disclose lobbying activities pursuant to 31 U.S.C. 1352
1. Type of Federal Action:
a. contract
b. grant
c. cooperative agreement
d. loan
e. loan guarantee
f. loan insurance
2. Status of Federal Action:
a. Bid/offer/application
b. Initial Award
c. Post-Award
3. Report Type:
a. initial filing
b. material change
For Material Change Only:
Year___________ Quarter____________
Date Of Last Report:_________________
4. Name and Address of Reporting Entity:
Prime
Subawardee Tier (if known) ________________________
Congressional District (if known) _________________________
5. If Reporting Entity in No. 4 is Subawardee, Enter Name
and Address of Prime:
Congressional District (if known) ________________________
6. Federal Department/Agency:
7. Federal Program Name/Description:
CFDA Number (if applicable) ________________________
8. Federal Action Number (if known)
9. Award Amount (if known) $
10. a. Name and Address of Lobbying Entity
(if individual, last name, first name, MI):
(attach Continuation Sheet(s) SF-LLL-A, if necessary)
b. Individuals Performing Services (including address if
different from No. 10a.) (last name, first name, MI):
(attach Continuation Sheet(s) SF-LLL-A, if necessary)
11. Amount of Payment (check all that apply):
$ € actual € planned
13. Type of Payment (check all that apply):
a. retainer
b. one-time fee
c. commission
d. contingent fee
e. deferred
f. other; specify: _____________________________
12. Form of Payment (check all that apply):
a. cash
b. In-kind; specify: Nature
Value
14. Brief Description of Services Performed or to be Performed and Date(s) of Services, including officer(s), employee(s), or
Member(s) contacted, for Payment Indicated in Item 11(attach Continuation Sheet(s) SF-LLL-A, if necessary):
15. Continuation Sheet(s) SF-LLL-A attached: Yes No
16. Information requested through this form is authorized by
title 31 U. S. C. section 1352. This disclosure of lobbying
activities is a material representation of fact upon which
reliance was placed by the tier above when this transaction
was made or entered into. This disclosure is required
pursuant to 31 U. S. C. 1352. This information will be
reported to the Congress semi-annually and will be
available for public inspection. Any person who fails to file
the required disclosure shall be subject to a civil penalty of
not less than $10,000 and not more than $100,000 for each
such failure.
Signature:
Print Name:
Title: ______________________________________________
Telephone No: Date:
Federal Use Only Authorized for Local Reproduction
Standard Form - LLL
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Contractor Certifications Required by North Carolina Law (Rev. 8/16;3/22) Page 1 of 1
State Certifications
Contractor Certifications Required by North Carolina Law
Instructions: The person who signs this document should read the text of the statutes and Executive Order listed below and consult
with counsel and other knowledgeable persons before signing. The text of each North Carolina General Statutes and of the Executive
Order can be found online at:
Article 2 of Chapter 64: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/ByArticle/Chapter_64/Article_2.pdf
G.S. 133-32: http://www.ncga.state.nc.us/gascripts/statutes/statutelookup.pl?statute=133-32
Executive Order No. 24 (Perdue, Gov., Oct. 1, 2009): https://ethics.nc.gov/media/242/download?attachment
G.S. 105-164.8(b): http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_105/GS_105-164.8.pdf
G.S. 143-48.5: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_143/GS_143-48.5.html
G.S. 143-59.1: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143/GS_143-59.1.pdf
G.S. 143-59.2: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143/GS_143-59.2.pdf
G.S. 143-133.3: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_143/GS_143-133.3.html
G.S. 143B-139.6C: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDF/BySection/Chapter_143B/GS_143B-139.6C.pdf
Certifications
(1) Pursuant to G.S. 133-32 and Executive Order No. 24
(Perdue, Gov., Oct. 1, 2009), the undersigned hereby
certifies that the Contractor named below is in
compliance with, and has not violated, the provisions of
either said statute or Executive Order.
(2) Pursuant to G.S. 143-48.5 and G.S. 143-133.3, the
undersigned hereby certifies that the Contractor named
below, and the Contractor’s subcontractors, complies
with the requirements of Article 2 of Chapter 64 of the
NC General Statutes, including the requirement for each
employer with more than 25 employees in North
Carolina to verify the work authorization of its
employees through the federal E-Verify system." E-
Verify System Link: www.uscis.gov
(3) Pursuant to G.S. 143-59.1(b), the undersigned hereby
certifies that the Contractor named below is not an
“ineligible Contractor” as set forth in G.S. 143-59.1(a)
because:
(a) Neither the Contractor nor any of its affiliates has
refused to collect the use tax levied under Article 5
of Chapter 105 of the General Statutes on its sales
delivered to North Carolina when the sales met one
or more of the conditions of G.S. 105-164.8(b); and
(b) [check one of the following boxes]
X Neither the Contractor nor any of its affiliates
has incorporated or reincorporated in a “tax
haven country” as set forth in G.S. 143-
59.1(c)(2) after December 31, 2001; or
☐ The Contractor or one of its affiliates has
incorporated or reincorporated in a “tax haven
country” as set forth in G.S. 143-59.1(c)(2) after
December 31, 2001 but the United States is not
the principal market for the public trading of the
stock of the corporation incorporated in the tax
haven country.
(4) Pursuant to G.S. 143-59.2(b), the undersigned hereby
certifies that none of the Contractor’s officers, directors,
or owners (if the Contractor is an unincorporated
business entity) has been convicted of any violation of
Chapter 78A of the General Statutes or the Securities Act
of 1933 or the Securities Exchange Act of 1934 within
10 years immediately prior to the date of the bid
solicitation.
(5) Pursuant to G.S. 143B-139.6C, the undersigned hereby
certifies that the Contractor will not use a former
employee, as defined by G.S. 143B-139.6C(d)(2), of
the North Carolina Department of Health and Human
Services in the administration of a contract with the
Department in violation of G.S. 143B-139.6C and that
a violation of that statute shall void the Agreement.
(6) The undersigned hereby certifies further that:
(a) He or she is a duly authorized representative of the
Contractor named below;
(b) He or she is authorized to make, and does hereby
make, the foregoing certifications on behalf of the
Contractor; and
(c) He or she understands that any person who
knowingly submits a false certification in response
to the requirements of G.S. 143-59.1and -59.2 shall
be guilty of a Class I felony.
Contractor’s Name:
Contractor’s
Authorized Agent: Signature Date
Printed Name Title
Witness: Signature Date
Printed Name Title
The witness should be present when the Contractor’s Authorized Agent signs this certification and should sign and date this
document immediately thereafter.
DocuSign Envelope ID: 9DDCE310-CD26-46F2-A88B-B5927F654D07
County Manager
Bonnie Hammersley
12/2/2022
Bonnie Hammersley
Clerk to the BoardLaura Jensen
12/2/2022
Contract Number 00045330, Amendment Number 1 / Page 15 of 15
DocuSign Envelope ID: 11914B3A-607E-46C7-AB4A-3AD9BACE9235
Revised 07/20
ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Party/Vendor Name: OCHD Party/Vendor Contact Person: Sharron Hinton Contact Phone: 919-245-2492
Party/Vendor Address: 300 West Tryon St City Hillsborough State: NC Zip: 27278 Department: OCHD Amount:
$44,774 Purpose: ESG FY22 Rapid Rehousing Budget Code(s): 32470605 442235 71084 Vendor # N/A (N/A if
new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal
Amendment Effective Date 8/14/2023 Approved by Board Yes No Agenda Date:
This agreement is approved as to technical form and content and I as Department Director affir matively state work on
this project has not been initiated prior to execution of the agreement:
Department Director’s Signature ________________________________________ Date: ________
Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that
was addressed:
Information Technologies
(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer___________________________________ Date: ________
Risk Management
This agreement is approved for sufficiency of insurance standards, specifications, and requirements:
Office of the Risk Management Officer___________________________________ Date: _________
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer ____________________________________ Date: _________
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney __________________________________________Date: ________
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board __________________________________________Date:_________
DocuSign Envelope ID: 11914B3A-607E-46C7-AB4A-3AD9BACE9235
9/8/2023
9/17/2023
9/18/2023
9/18/2023