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2023-544-E-Health Dept-Transplanting Traditions -Outside Agency Agreement
Orange County Outside Agency Performance Agreement Revised 06/23—County Manager Version Page 1 of 10 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, Post Office Box 8181, Hillsborough, North Carolina, 27278, ("County") and Transplanting Traditions Community Farm, Inc., a not- for-profit corporation, located at 2912 B Jones Ferry Rd., Chapel Hill, North Carolina 27516 (“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, as outlined in the attached Outside Agency Funding Application and any amendments or revision thereto which is attached as Exhibit “A” and incorporated by reference, to the residents of Orange County. The Scope of Services 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 B. 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 for the provision of services described in Exhibit A, Scope of Services and more particularly described in the Revised Program Budget, the maximum sum of $12,000. b. All funds appropriated shall be used for purposes described in Exhibit A. 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, at the discretion of the County the Provider may be required to repay the funds to the County. c. The Provider shall be paid in four equal installments in the amount of $3,000. 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. d. 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. DocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Orange County Outside Agency Performance Agreement Page 2 of 10 Rev.06/23 e. Once Provider has satisfied its obligations as provided in (d) 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. f. 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 8, April 8 and July 8 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. Termination for Cause. In the event of any of the circumstances set forth below (hereinafter referred to as “default”), the County may immediately terminate this Agreement, in whole or in part, and from time to time. Notice of termination must be in writing, state the reason or reasons for the termination, and specify the effective date of the termination: i. In the event that Provider shall cease to exist as an organization or shall enter bankruptcy proceedings, be declared insolvent, or liquidate all or substantially all of its assets, or significantly reduce its services or accessibility to Orange County residents during the term of this Agreement; or 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 DocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Orange County Outside Agency Performance Agreement Page 3 of 10 Rev.06/23 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. e. Waiver. The payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. 6. Responsibilities of the County. Cooperation and Coordination. The County has designated (Quintana Stewart) to act as the County's representative with respect to the Project who shall have the authority to render decisions within guidelines established by the County Manager or the County Board of Commissioners and who shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. 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. Cyber Liability. For protection from claims resulting from data breach, virus, and cyberattack; iii. 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; iv. Comprehensive Automobile Liability Insurance, including hired and non-owned vehicles, if any, covering personal injury or death, and property damage; and v. 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. vi. Sexual Misconduct. Sexual Abuse/Molestation Insurance is required when Provider works directly one-on-one with children, elderly or other at-risk populations. 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 ‐ DocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Orange County Outside Agency Performance Agreement Page 4 of 10 Rev.06/23 Statutory State NC, for each employee Limits for Coverage B ‐ Employers Liability of: $1 million Each Occurrence $1,000,000 BID limit • Cyber Liability $1,000,000 Each Occurrence; $2,000,000 Aggregate *Only required for agencies transmitting personal identifiable information that is disseminated electronically. • Commercial General $1,000,000 Each Occurrence Liability $2,000,000 Aggregate • Automobile Liability $1,000,000 Each Occurrence *Only required for agencies doing travel as part of the agreement with the County. • Professional Liability $1,000,000 Each Occurrence $2,000,000 Aggregate • Sexual Misconduct $1,000,000 Each Occurrence $2,000,000 Aggregate *Only required for agencies doing direct work with minors (under the age of 18). 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. For more information see the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements, (each document is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php.) 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. 8. General Provisions. a. 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. 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 identified, on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of DocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Orange County Outside Agency Performance Agreement Page 5 of 10 Rev.06/23 any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. b. 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, which is incorporated herein by reference and can be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php. The County may enforce this provision by an 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. c. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. d. 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 Orange County Living Wage Policy, which is incorporated herein by reference, can be viewed at: http://www.orangecountync.gov/departments/purchasing_division/contracts.php. The County’s living wage is $15.85 per hour. To the extent possible, Orange County recommends that Provider provide a living wage to its employees. e. 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. f. 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. g. 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. h. 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. i. 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 DocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Orange County Outside Agency Performance Agreement Page 6 of 10 Rev.06/23 injury, including death or property damage, to any person or persons caused in whole or in part by the negligence or willful misconduct of the Provider, except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this section to require Provider to indemnify the County to the extent permitted under North Carolina law. Nothing in this section is intended to affect or abrogate the County’s sovereign immunity defenses. j.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. k. 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. l.Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the Provider and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. m.Notices. Any notice required by this Agreement shall be in writing and delivered by certified or registered mail, return receipt requested to the following: Provider’s Name Transplanting Traditions Attention: Ree Ree Wei Address: 2912 B Jones Ferry Rd. Chapel Hill, NC 27516 Orange County Attention: Kimberlee Quatrone P.O. Box 8181 Hillsborough, NC 27278 Email:kquatrone@orangecountync.gov Email: hrwei@transplantingtraditions.org n. 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 _____________________________ _______________________ Ree Ree Wei, Executive Director Date For and on behalf of Orange County Government _______________________________ ________________________ Bonnie Hammersley, County Manager Date DocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 9/26/2023 10/5/2023 Orange County Outside Agency Performance Agreement Page 7 of 10 Rev.06/23 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: Transplanting Traditions Party/Vendor Contact Person: Ree Ree Wei Contact Phone: 984-212- 4621 Party/Vendor Address: 2912 B Jones Ferry Rd. City Chapel Hill State: NC Zip: 27516 Department: Health Amount: $12,000 Purpose: Outside Agency Agreement Budget Code(s): 10290050-720278 Vendor # 65780 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 7-1-23 Approved by Board Yes No Agenda Date: June 20, 2023 This agreement is approved as to technical form and content and I as Department Director affirmatively state work on this project has not been initiated prior to execution of the agreement: Department Director’s Signature ________________________________________ Date: ________ Agreements for emergency services or repair are not subject to the above affirmation. If services related to this agreement have already begun or been completed please briefly describe the nature of the emergency condition that was addressed: Information Technologies (Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Risk Management This agreement is approved for sufficiency of insurance standards, specifications, and requirements: Office of the Risk Management Officer___________________________________ Date: _________ Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: Office of the Chief Financial Officer ____________________________________ Date: _________ Legal Services This agreement is approved as to legal form and sufficiency: Office of the County Attorney __________________________________________Date: ________ Clerk to the Board Received for record retention: All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 9/27/2023 10/2/2023 10/3/2023 10/5/2023 Cover Page P a g e 6 o f 32 COVER PAGE Applicant Contact Information Applicant Organization’s Legal Name: Transplanting Traditions Community Farm Applicant Organization’s Physical Address: 2912B Jones Ferry Road, Chapel Hill, NC, 27516 Applicant Organization’s Mailing Address: PO Box 394, Carrboro, NC, 27510 Applicant Organization’s Web Address: transplantingtraditions.org Executive Director: Ree Ree Wei Telephone Number: 984-212-4621 E-Mail: hrwei@transplantingtraditions.org Tax ID Number: 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 Youth & Children’s Program $5,000 Workshops/ Trainings/Travel $12,000 Personnel $5,000 Workshops/ Trainings/Travel $22,000 Health Food Access Program $8,000 Operations & Personnel $15,000 Personnel & Food Purchase from farmers $7000 Workshops Trainings $30,000 Totals $13,000 $27,000 $12,000 52,000 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. Funds will be used to support 1) farmer capacity building, coordination and distribution of fresh local and culturally appropriate food to food insecure refugee and immigrant families 2) academic support, tutoring, cultural and leadership development for children and youth from Burma. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Cover Page P a g e 7 o f 32 Signature: 1/12/2023 _________ Executive Director Date Signature: 1/12/2023 Board Chairperson Date Application Signatures: Please submit a wet signature or electronic signature, MS Word cursive fonts are not acceptable. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Cover Page P a g e 8 o f 32 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. Transplanting Traditions hires refugee program participants as staff in order to provide economic and job skills development opportunities within the refugee community and to ensure community and cultural relevance of programs. Currently, two three staff members are the adult children of farmer participants. In addition, one TTCF farmer participant and one youth program parent serves on the TTCF board of directors. Participants work on staff to help deliver highest quality programming and ensure that the organizational decisions and programs are driven by and lead by those most impacted by the work. All staff that have family members that are beneficiaries are overseen by a staff member who is NOT a current beneficiary of the program for which funds are being requested. 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 t he program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. Signature: 1/12/2023 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Cover Page P a g e 9 o f 32 Executive Director Date Signature: 1/12/2023 Board Chairperson Date Application Signatures: Please submit a wet signature or electronic signature, MS Word cursive fonts are not acceptable. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Program information P a g e 10 o f 32 AGENCY INFORMATION Please provide the following information about your agency: 1. Date of Incorporation (Month/Year): February 2018 2. Agency’s Purpose/Mission (no more than a few sentences): Transplanting Traditions Community Farm (TTCF) facilitates resources and support for refugees and immigrants to foster a healthier community, improve livelihoods, and maintain agricultural traditions as they build new lives in North Carolina. The heart of TTCF is an eight-acre farm in Chapel Hill, Orange County where refugee families grow food, build farm businesses, celebrate culture, and create a sense of home. The farm is at the core of TTCF’s Youth Leadership programs, providing space for refugee youth ages 5-18 to explore identity, leadership, culture, and community, and also supports TTCF’s hunger reduction programs including the Health Food Access Program, an innovative model that provides food insecure refugee families a share of the culturally appropriate traditional produce grown by TTCF refugee farmers. Founded in 2009 as a project of the Orange County Partnership for Young Children, TTCF became an independent 501(c)(3) in 2018 to focus more deeply on serving refugees and immigrants through the lens of food, agriculture, and social justice. 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). TTCF has worked with 100+ refugee families throughout the area for more than a decade, providing food access, land access, training, infrastructure, administrative support, businesses development, child and youth education, and more to the refugee community. Through this work, TTCF refugee farmers have developed successful businesses, generating more than 1 million dollars in income and producing over 100,000 pounds of food per year, reaching more than 10,000 individuals, 20% of which are food insecure. TTCF youth and children program has worked with 121 participants since 2011, ensuring academic success, cultivating culture and leadership, many participants becoming leaders throughout the state. 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: 5 # of FTE – Part-Time Paid Positions: 4, 2 AmeriCorps VISTA positions 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? Each year, TTCF review and updates organizational goals based on input from participants, community members, board members, staff members and volunteers. In 2022, the goals were updated and while racial, cultural, economic, environmental and language equity and justice are embedded in all of our goals, our goals EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Program information P a g e 11 o f 32 outline what we seek to achieve. following highlight the organizational goals that outline our racial equity work most explicitly. The goals are outlined at the end of this response. In addition to working towards increased racial equity through our organizational goals, we also promote racial equity through direct representation in our organization’s makeup. We focus on TTCF’s inclusive organizational structure and culture, and the strategic steps we’ve been taking to ensure our work, internally and externally, is actively anti-racist. At present, seven of TTCF’s 11 staff and AmeriCorps members are from the community of ethnic minority Southeast Asian refugees we work with. They span business development, farm management and design, greenhouse management, food distribution, youth education, and media and communications. Our Executive Director, Ree Ree Wei, is the daughter of two of our longest-standing partner farmers, Zar Ree and Lion Wei, who resettled in the U.S in 2006. We are thrilled to be working as a team on increasing refugee representation across TTCF’s decision-making roles and on our board. Three of our current staff are former TTCF Youth Program participants, and the staff for our Children’s Summer Camp as well as our tutoring program are current and former Youth Program participants. Moreover, five staff members are also individuals that have active farm businesses at TTCF, or previously were active farmers. TTCF is accountable to refugee farmers in our community and to the larger refugee population across the state. By aligning our organization’s leadership and internal structuring with the values and culture of the farmers and farming families we work alongside, we aim to help advance long-term racial and refugee justice. Accordingly, our project is setting up new systems, including training, mentorship, and other support, so that rising leaders in our community are well-equipped to steward a financially and programmatically successful operation, far into the future. We are also redesigning how we fund both projects and people, and plan to incorporate more sustainable funding models, for instance, increased funding of TTCF leadership by direct farm sales. For your reference, Transplanting Traditions’ current organizational goals are included here. A number of these we have already accomplished and others are already underway. • Be an organization whose culture, values, and mission support the leadership and vision of the refugee community from Burma o Objectives 1a: Increased & shared understanding and awareness of harmful and oppressive power dynamics that are visible and hidden and the impacts they have to TTCF and each person individually o Objective 1b: Increased anti-racist and non-oppressive practices as an organization and individually for all staff o Objective 1c: To have a mission, vision and programming that is anti-racist and is defined by the needs of the participants and the larger refugee community from Burma • TTCF to be led by and decisions made predominantly by the refugee community and participants from Burma. o Objective 2a: Define a culturally appropriate governing/board structure that supports the Executive Director, farmers and programming by end of 2022 o Objective 2b: Develop and form the new group of governance leaders/members by July 2023 o Objective 2c: Led by an Executive Director that identifies as a refugee from Burma and increased diversity throughout the staff. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Program information P a g e 12 o f 32 • All participants and staff have the skills and knowledge to lead, and make decisions on programs, and organization operation o Objective 3a: Increase participants, staff and board skills and knowledge about 1) farming, 2) funding and finance, 3) technology, data & communications and 4) people management and facilitation o Objective 3b: Organizational leaders (staff & board) and participants are able to make collective decisions for the betterment of the organization and the programs • Systems, procedures, and policies facilitate accountability while also balancing a diverse range of values, cultures. o Objective 4b: Operational systems are secure, efficient, effective and easy to manage. Objective 4c: Policies and procedures are fair, and aligned with the organizational values and mission 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). The Healthy Food Access Program and the Youth and Children Programs were both originally developed per the request active farmer participant families, to meet the needs of their own children and the food access gaps. In addition to participants and former participants serving in leadership roles on the staff and board, Transplanting Traditions participants also serve on decision making committees that meet monthly to inform organizational decisions, programs and technical assistance as well as provide dedicated spaces for feedback. In addition, extensive mid-year and end of year feedback process evaluation is gathered from each farmer in the form of conversational interviews to understand how the organizational structure and programs can improve annually to best serve farmer needs. The majority of workshops and trainings, led by refugee-identifying staff, to offer farmers tools and skills to build their leadership capabilities at the organizational level and for their independent businesses. TTCF’s approach in designing this project was through community consultations to discuss the overall community need of secure land and business development, meeting with farmers one-on-one to learn about their business goals and needs, and addressing challenges together. 7. Please fill in your agency demographics in the table below: 9 staff, 2 AmeriCorps VISTA Agency Demographics Staff Board Gender Men 1 0 Women 10 5 Nonbinary/Genderqueer Self-Describe Total 11 5 Race and Ethnicity Black or African-American 1 1 American Indian or Alaska Native Asian Indian White 3 2 Native Hawaiian or Other Pacific Islander Chinese EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Program information P a g e 13 o f 32 Japanese Vietnamese Filipino Korean Some other race 7 2 Total 11 5 Of the above, how many Hispanic, Latino or Spanish origin 0 0 Of the above, how many non-Hispanic, Latino or Spanish origin 11 5 Total 11 5 8. Please describe any activities your organization is doing to address racial equity. a. % of staff that have attended racial equity training: 100% b. % of board that have attended racial equity training: 60% c. Any additional activities: PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 9. Program Name: Healthy Food Access Program Program Primary Contact and Title: Ree Ree Wei Telephone Number: 984-212-4621 E-Mail: hrwei@transplantingtraditions.org 10. Please briefly describe the proposed program, including an explanation of how it aligns with the Town of Chapel Hill and Carrboro’s Results Framework, and Orange County BOCC Goals and Priorities, and the target population to benefit from the program. (250 words or less) Given the language, education, and cultural barriers, employment options for refugees are limited to poorly compensated jobs in service industries. As a result, refugee families often struggle to meet basic household needs, the majority in Orange County being low income and food insecure. Those that do seek food assistance struggle to access culturally appropriate foods is critical to a healthy culturally rooted diet, adding to the burden of chronic disease in the refugee community. The Healthy Food Access Program meets immediate needs of the local refugee community through traditional food distribution, while also addressing root causes of food insecurity by increasing, for the long term, refugee farmers’ capacity to grow produce—both for their own households and for others in the community. The core goals of this program are to increase access to healthy, culturally relevant food for refugee and immigrant families experiencing food insecurity; boost refugee farmers’ capacity; and improve the overall physical, financial, and mental health of the larger local refugee and immigrant community, getting more produce into the homes of the local refugee community. The Healthy Food Access program uses monetary donations from private and public donors to purchase Southeast Asian produce grown by partner farmers from TTCF. In partnership with local hunger relief organizations, such as PORCH and the Refugee Support Center the produce is then distributed into the EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Program information P a g e 14 o f 32 community providing refugee families with culturally appropriate produce that they know how to healthily, lovingly prepare. Since 2015, this program has helped more than 6000 food insecure individuals access culturally healthy food. 11. Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics Projected 2021-2022 Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 Gender Men 504 840 836 948 Women 644 910 915 1031 Nonbinary/Genderqueer 0 0 0 0 Self-Describe 0 0 0 0 Total 1148 1750 1751 1979 Race and Ethnicity Black or African-American American Indian or Alaska Native Asian Indian White Native Hawaiian or Other Pacific Islander Chinese Japanese Vietnamese Filipino Korean Some other race 1148 1750 1751 1979 Total 1148 1751 1751 1979 Of the above, how many Hispanic, Latino or Spanish origin 0 0 0 30 Of the above, how many non-Hispanic, Latino or Spanish origin 1148 1750 1751 1949 Total 1148 1750 1751 1979 Age 0-5 years 158 135 31 198 6-18 years 389 358 461 495 19-50 years 511 965 922 1047 51+ years 90 292 338 239 Total 1148 1750 1751 1979 Geographic Location Town of Chapel Hill 697 1193 1237 1384 Town of Carrboro 325 189 293 316 Orange County (Outside of Chapel Hill/Carrboro) 88 127 87 110 Outside of Orange County 38 242 134 169 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Program information P a g e 15 o f 32 Total 1148 1750 1751 1979 Income Low-income (80% of the Area Median Income and Below) Please see income table in the attachments 100% 100% 100% 100% Total 1148 1750 1751 1979 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 118,035 118,867 168,768 Total # of Individuals 1750 1751 1979 Cost Per Individual $67 $67 $85 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: Healthy Food Access Program Strategic Objective (please choose one from the Results Framework) Children improve their educational outcomes Residents Increase their livelihood security X Residents improve their health outcomes Intermediate Result 3.2: Residents demonstrate new healthy lifestyle behaviors RESULTS Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 Performance Indicators # of people reporting healthier functionality and lifestyle behaviors (improved nutrition and access to healthy food, stress reduction practices, exercise at least 30min 3x a week.). 100% of 12 heads of household reporting on behalf of 57 total household participants, report that all household member, or 57 people total, improve their 100% of 12 heads of household reporting on behalf of 57 total household participants, report that all household member, or 57 people total, improve their 100% of 23 heads of household reporting on behalf of 109 total household participants, report that all household member, or 109 people total, improve their EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Program information P a g e 16 o f 32 nutrition, physical activity and stress reduction practices nutrition, physical activity and stress reduction practices nutrition, physical activity and stress reduction practices % and # of program participants that consume fresh local food 100% of 1,750 participants consume fresh food on a weekly or twice monthly basis 100% of 1,751 participants consume fresh food on a weekly or twice monthly basis 90% of 1,979 participants consume fresh food on a weekly or monthly basis % and # of program participants who access culturally appropriate fresh fruits and vegetables 100% of 1,750 participants access culturally appropriate fresh fruits and vegetables on a weekly or twice mo nthly basis 100% of 1,751 participants access culturally appropriate fresh fruits and vegetables on a weekly or twice monthly basis 100% of 1,979 participants access culturally appropriate fresh fruits and vegetables on a weekly monthly basis EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Program information P a g e 17 o f 32 PROGRAM INFORMATION *Please submit for each program if applying for funding for more than one program. 9. Program Name: Youth & Children’s Program Program Primary Contact and Title: Ree Ree Wei Telephone Number: 984-212-4621 E-Mail: hrwei@transplantingtraditions.org 10. Please briefly describe the proposed program, including an explanation of how it aligns with the Town of Chapel Hill and Carrboro’s Results Framework, and Orange County BOCC Goals and Priorities, and the target population to benefit from the program. (250 words or less) At 1,300 individuals, refugees from Burma represent 90% of Orange County’s refugee community; 60% are youth, being the largest youth minority group in Chapel Hill. TTCF serves, annually, 30+ refugee children (3 to 13) and 15+ refugee youth (14 to 19). Refugee children and youth face obstacles such as financial insecurity and navigating US schools. They are often ad-hoc interpreters and translators for their parents’ and grandparents’, navigating difficult healthcare, human services, and other systems on behalf of their families which often leads to anxiety, loneliness and depression. Many face struggles in school or want to access further education, but often do not have the historical knowledge or parental support to help them accomplish these goals. Since 2013, the TTCF Refugee Youth and Children’s Program (RYCP) has addressed these challenges and concerns. The program was conceived by refugee farmers watching their children grapple with these challenges of culture, language, education and belonging as they matured from childhood into young adulthood. The primary purpose of the RYCP is to provide opportunities for refugee youth and children to develop leadership skills and reach educational goals, while exploring complex cultural identities and barriers that undermine their success. The RYCP supports low-income refugee youth and children from Burma by 1) increasing learning outcomes and college access; 2) improving sense of cultural identity and mental health; and 3) increasing capacity to serve as leaders. Activities include tutoring, summer camp at the farm, coaching and mentoring, conferences and field trips and wellness and mental health activities. 11. Target Population: Please complete the table below with numbers (not percentages) of individuals served and projected to be served. Program Target Population Demographics Projected 2021-2022 Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 Gender Men 25 20 Women 25 30 Nonbinary/Genderqueer 0 0 Self-Describe 0 0 Total n/a n/a 50 50 Race and Ethnicity Black or African-American EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Program information P a g e 18 o f 32 American Indian or Alaska Native Asian Indian White Native Hawaiian or Other Pacific Islander Chinese Japanese Vietnamese Filipino Korean Some other race 50 50 Total n/a n/a 50 0 Of the above, how many Hispanic, Latino or Spanish origin 0 0 Of the above, how many non-Hispanic, Latino or Spanish origin 50 50 Total n/a n/a 50 0 Age 0-5 years 10 12 6-18 years 40 38 19-50 years 51+ years Total n/a n/a 50 50 Geographic Location Town of Chapel Hill 44 30 Town of Carrboro 5 4 Orange County (Outside of Chapel Hill/Carrboro) 0 8 Outside of Orange County 1 8 Total n/a n/a 50 50 Income Low-income (80% of the Area Median Income and Below) Please see income table in the attachments 100% 100% Total n/a n/a 50 50 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 n/a $62,755 $148,081 Total # of Individuals n/a 50 50 Cost Per Individual n/a $1255 $2961 13. Performance Indicators EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Program information P a g e 19 o f 32 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: Refugee Youth & Children’s Program Strategic Objective) ✓ Children improve their educational outcomes Residents Increase their livelihood security Residents improve their health outcomes Intermediate Result 1.2: Children demonstrate new grade-level-appropriate skills RESULTS Actual 2021-2022 Projected 2022-2023 Projected 2023-2024 Performance Indicators % and # of program participants that improve grades by end of program period n/a 75% of 50 program participants improve grades 75% of 50 program participants improve grades % and # of program participants that are promoted to the next grade n/a 95% and 50 of youth and children program participants are promoted to the next grade 95% and 50 of youth and children program participants are promoted to the next grade % and # of program participants that express greater confidence in their ability to be successful at school n/a 75% of 50 program participants express greater confidence in their ability to be successful at school 75% of 50 program participants 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 n/a 90% of 50 express greater confidence in their leadership and pro-social abilities. 75% of 50 express greater confidence in their leadership and pro-social abilities. % and # of program participants who graduate from high school and access higher education plan on attending post-secondary education n/a 85% of 10 program participants who plan on attending post-secondary education (written a little differently last year) 100% of participants graduate high school and 70% access higher education upon completion. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Outside Agencies/Human Services Program information P a g e 20 o f 32 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 Farmer participants measurably improve their capacity and knowledge to grow and meet the increased need for fresh food _________________ EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Outside Agencies/Human Services Program information P a g e 21 o f 32 for the community while also improving business operations and increasing income through farm sales Performance Measure (How will you accomplish your goal?) Percentage of participants who attend TTCF’s small business and agricultural trainings and who demonstrate an increase in farm income and business growth Actual Results (Outcome) Ending FY2022 100% of 20 participants measurably improved their small business, small farming, and marketing skills, resulting in improved business operations and income through farm sales. Overall farm sales increased 19% from $234,204 to $271,020 From 2021 to 2022 Projected Results (Outcome) Ending FY2023 100% of 20 participants will measurably improve their small business, small farming, and marketing skills, resulting in improved business operations and income through farm sales. Projected Results (Outcome) Ending FY2024 100% of 28 participants will measurably improve their small business, small farming, and marketing skills, resulting in improved business operations and income through farm sales. Program Goal # 2 Participants report healthier functionality and lifestyle behaviors (improved nutrition and access to healthy food, stress reduction practices, exercise at least 30min 3x a week.) Performance Measure (How will you accomplish your goal?) Number of participants that report that all household members improve at least one of the following: their nutrition, physical activity and mental health. Actual Results (Outcome) Ending FY2022 100% of 12 households reporting for 57 individuals report an improvement in at least one of the following: their nutrition, physical activity and mental health EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Outside Agencies/Human Services Program information P a g e 22 o f 32 Projected Results (Outcome) Ending FY2023 100% of 12 households reporting for 57 individuals report an improvement in at least one of the following: their nutrition, physical activity and mental health Projected Results (Outcome) Ending FY2024 100% of 23 households reporting for 109 individuals report an improvement in at least one of the following: their nutrition, physical activity and mental health Program Goal # 3 Participants grow healthy, fresh food which is distributed to refugee and immigrant families on a weekly to bi-monthly basis who are able to reduce their food insecurity and consume fresh, culturally appropriate food Performance Measure (How will you accomplish your goal?) Number of food insecure participants accessing and consuming fresh, culturally appropriate food through TTCF’s “Share a Share” hunger relief program. Survey results from participants qualify the success of the program. Actual Results (Outcome) Ending FY2023 100% of 1,750 food insecure participants access culturally appropriate fresh fruits and vegetables. Projected Results (Outcome) Ending FY2023 100% of 1,751 food insecure participants access culturally appropriate fresh fruits and vegetables. Projected Results (Outcome) Ending FY2024 100% of 1,979 food insecure participants access culturally appropriate fresh fruits and vegetables. EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATIONDocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 Certified by: _______________________ Title: __________________________ Date: ____________ (Provider’s Signature) EXHIBIT “B” Scope of Services – FY 2023-24 Outside Agency Performance Agreement Agency Name: Transplanting Traditions Community Farm Program Name: Health Food Access Program and Youth & Children's Program Funding Award: $12,000 Outline how the agency will spend Orange County’s funding award. Program Services Outline the critical services (activities) the agency will employ to attain the Anticipated Outcomes below, by June 30, 2024. • • • 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 Percentage of 28 participants who attend TTCF’s small business and agricultural trainings and who demonstrate an increase in farm income and business growth 100% of 28 participants 23 Households reporting for 109 individuals/participants that report that all household members improve at least one of the following: their nutrition, physical activity and mental health. 100% of 23 households reporting for 109 individuals Number of food insecure 1979 participants accessing and consuming fresh, culturally appropriate food through TTCF’s “Share a Share” hunger relief program. Survey results from participants qualify the success of the program. 100% of 1,979 food insecure participants Expense Description Amount Workshops, Trainings, & Travels - Youth & Children's Program $5,000 Workshops Trainings - Healthy Food Access Program $7,000 Provide academic support, tutoring, cultural and leadership development for children and youth from Burma. 9/8/2023Executive Director Provide agricultural education to farmers, conduct end of year interview, and track their income and food savings from farming and receiving of food. DocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227 9/26/2023 Orange County Outside Agency Performance Agreement Page 10 of 10 Rev.06/23 ATTACHMENT “A” Orange County Certifications – FY 2023-2024 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: D2C31311-1A1A-4A30-9007-2F17D64E6227 Executive Director 9/26/2023 01/20/2023 Sentinel Risk Advisors LLC 4700 Six Forks Road Suite 200 Raleigh NC 27609 Ashley Riley (919) 926-4623 (919) 926-4664 ariley@sentinelra.com Transplanting Traditions Community Farm, Inc. P O Box 394 Carrboro NC 27510 StarNet Insurance Company 040045 SummitPoint Insurance Company 15136 CL2312015168 A Deductible $0 Y 8531699-10 01/21/2023 01/21/2024 1,000,000 300,000 5,000 1,000,000 3,000,000 3,000,000 A Y 8531699-10 01/21/2023 01/21/2024 1,000,000 A 0 Y 8531699-10 01/21/2023 01/21/2024 1,000,000 1,000,000 B WCS3013510 01/21/2023 01/21/2024 1,000,000 1,000,000 1,000,000 A Abuse or Molestation 8531699-10 01/21/2023 01/21/2024 Each Claim $1,000,000 Aggregate $3,000,000 Certificate Holder named Additional Insured (for ongoing & completed operations) on General Liability, Auto Liability and Umbrella Liability Coverage per written contract. Orange County Government P O Box 8181 Hillsborough NC 27278 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY DocuSign Envelope ID: D2C31311-1A1A-4A30-9007-2F17D64E6227