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Home My WebLink About2023-662-E-DEAPR-North Carolina Department of Agriculture and Consumer Services-Annual Contract Update for NCADFP Grant Contract for matched funds09/18/2023 2023-2024 Annual Contract Attachment Completion Instructions -Governmental You are receiving this packet because your entity has an active contract(s) or is being offered a contract(s) with the Agricultural Development and Farmland Preservation (ADFP) Trust Fund. In order to receive payments from the ADFP Trust Fund, each form in this packet must be completed and signed every 12 months. Please follow the instructions below for completing and signing the forms. Contact the ADFP Trust Fund Document Specialist, Sarah Weavil, at sarah.weavil@ncagr.gov or 919-707-3072 with questions. Please complete, sign in blue or black ink, and return each of the included forms. A scanned/electronic copy is acceptable and can be emailed to ADFP. All forms need to be dated at the time of signing. Below are the portions of the contract that require completion.. 1.Complete and sign the Certifications and Assurances in Attachment C. Place of performance is your office’s physical address. 2.Complete NC OpenBook Supplemental Information in Attachment D. 3.Complete and sign Signature Card in Attachment E (Authorized Governmental Official and Chief Fiscal Officer signatures). 4.Complete and sign Substitute W-9 form in Attachment F. This form must be dated at the time of signing. 5.Attach a copy of a voided check or a letter from your bank, complete, and sign the Vendor Electronic Payment Form in Attachment G. f there has been no change to your entity’s information, the form still needs to be completed, signed, and attached with a voided check or letter. This form must be dated at the time of signing Please email the completed packet to Sarah Weavil at sarah.weavil@ncagr.gov. If you are sending original copies, please return the completed packet via FedEX or UPS (not USPS) with a tracking number to: Veronica Jamison, Office Manager N.C. Department of Agriculture & Consumer Services, Farmland Preservation 2 W. Edenton Street, Raleigh, NC 27601 Please return the completed packet within 10 working days (see policy below). If you are unable to meet the deadline, please email Sarah within 10 working days of original receipt with the reason for the delay. If a selected grant recipient fails to return a completed grant contract by the stipulated deadline, ADFP Trust Fund will notify the selected grant recipient in writing as a warning. The selected grant recipient will be allowed a grace period of 10 working days from the date of correspondence to return the completed contract. After the stipulated grace period, the offer will be rescinded and the grant funding reallocated. (Approved by the ADFP Trust Fund Advisory Committee 12/09/08) DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 PUBLIC SECTOR CONTRACTS (Including Local Governments) NCDA&CS - General Terms and Conditions – Public - Local Governmental Entities Eff. 07/14;4/15;1/17 Page 1 of 4 General Terms and Conditions DEFINITIONS Unless indicated otherwise from the context, the following terms shall have the following meanings in this Contract. All definitions are from 9 NCAC 3M.0102 unless otherwise noted. If the rule or statute that is the source of the definition is changed by the adopting authority, the change shall be incorporated herein: (1)"Agency" (as used in the context of the definitions below) shall mean and include every public office, public officer or official (State or local, elected or appointed), institution, board, commission, bureau, council, department, authority or other unit of government of the State or of any county, unit, special district or other political subagency of government. For other purposes in this Contract, “Agency” shall mean the entity identified as one of the parties hereto. (2)"Audit" means an examination of records or financial accounts to verify their accuracy. (3)"Certification of Compliance" means a report provided by the Agency to the Office of the State Auditor that states that the Grantee has met the reporting requirements established by this Subchapter and included a statement of certification by the Agency and copies of the submitted grantee reporting package. (4)"Compliance Supplement" refers to the North Carolina State Compliance Supplement, maintained by the State and Local Government Finance Agency within the North Carolina Department of State Treasurer that has been developed in cooperation with agencies to assist the local auditor in identifying program compliance requirements and audit procedures for testing those requirements. (5)"Contract" means a legal instrument that is used to reflect a relationship between the agency, grantee, and subgrantee. (6)"Fiscal Year" means the annual operating year of the non-State entity. (7)"Financial Assistance" means assistance that non-State entities receive or administer in the form of grants, loans, loan guarantees, property (including donated surplus property), cooperative agreements, interest subsidies, insurance, food commodities, direct appropriations, and other assistance. Financial assistance does not include amounts received as reimbursement for services rendered to individuals for Medicare and Medicaid patient services. (8)"Financial Statement" means a report providing financial statistics relative to a given part of an organization's operations or status. (9)"Grant" means financial assistance provided by an agency, grantee, or subgrantee to carry out activities whereby the grantor anticipates no programmatic involvement with the grantee or subgrantee during the performance of the grant. (10)"Grantee" has the meaning in G.S. 143C-6- 23(a)(2): a non-State entity that receives a grant of State funds from a State agency, department, or institution but does not include any non-State entity subject to the audit and other reporting requirements of the Local Government Commission. For other purposes in this Contract, “Grantee” shall mean the entity identified as one of the parties hereto. (11)"Grantor" means an entity that provides resources, generally financial, to another entity in order to achieve a specified goal or objective. (12)"Non-State Entity" has the meaning in N.C.G.S. 143C-1-1(d)(18): Any of the following that is not a State agency: an individual, a firm, a partnership, an association, a county, a corporation, or any other organization acting as a unit. The term includes a unit of local government and public authority. (13)"Public Authority" has the meaning in N.C.G.S. 143C-1-1(d)(22): A municipal corporation that is not a unit of local government or a local governmental authority, board, commission, council, or agency that (i) is not a municipal corporation and (ii) operates on an area, regional, or multiunit basis, and the budgeting and accounting systems of which are not fully a part of the budgeting and accounting systems of a unit of local government. (14)"Single Audit" means an audit that includes an examination of an organization's financial statements, internal controls, and compliance with the requirements of federal or State awards. (15)"Special Appropriation" means a legislative act authorizing the expenditure of a designated amount of public funds for a specific purpose. (16)"State Funds" means any funds appropriated by the North Carolina General Assembly or collected by the State of North Carolina. State funds include federal Attachment A DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 PUBLIC SECTOR CONTRACTS (Including Local Governments) NCDA&CS - General Terms and Conditions – Public - Local Governmental Entities Eff. 07/14;4/15;1/17 Page 2 of 4 financial assistance received by the State and transferred or disbursed to non-State entities. Both federal and State funds maintain their identity as they are subgranted to other organizations. Pursuant to N.C.G.S. 143C-6-23(a)(1), the terms "State grant funds" and "State grants" do not include any payment made by the Medicaid program, the Teachers' and State Employees' Comprehensive Major Medical Plan, or other similar medical programs. (17)"Subgrantee" has the meaning in G.S. 143C-6-23(a)(3): a non-State entity that receives a grant of State funds from a grantee or from another subgrantee but does not include any non-State entity subject to the audit and other reporting requirements of the Local Government Commission. (18) "Unit of Local Government has the meaning in G.S. 143C-1-1(d)(29): A municipal corporation that has the power to levy taxes, including a consolidated city-county as defined by G.S. 160B-2(1), and all boards, agencies, commissions, authorities, and institutions thereof that are not municipal corporations. Relationships of the Parties Independent Contractor: The Grantee is and shall be deemed to be an independent Contractor in the performance of this Contract and as such shall be wholly responsible for the work to be performed and for the supervision of its employees. The Grantee represents that it has, or shall secure at its own expense, all personnel required in performing the services under this agreement. Such employees shall not be employees of, or have any individual contractual relationship with, the Agency. Subcontracting: The Grantee shall not subcontract any of the work contemplated under this Contract without prior written approval from the Agency. Any approved subcontract shall be subject to all conditions of this Contract. Only the subcontractors or subgrantees specified in the Contract documents are to be considered approved upon award of the Contract. The Agency shall not be obligated to pay for any work performed by any unapproved subcontractor or subgrantee. The Grantee shall be responsible for the performance of all of its subgrantees and shall not be relieved of any of the duties and responsibilities of this Contract. Subgrantees: The Grantee has the responsibility to ensure that all subgrantees, if any, provide all information necessary to permit the Grantee to comply with the standards set forth in this Contract. Assignment: No assignment of the Grantee's obligations or the Grantee's right to receive payment hereunder shall be permitted. However, upon written request approved by the issuing purchasing authority, the State may: (a)Forward the Grantee's payment check(s) directly to any person or entity designated by the Grantee, or (b)Include any person or entity designated by Grantee as a joint payee on the Grantee's payment check(s). In no event shall such approval and action obligate the State to anyone other than the Grantee and the Grantee shall remain responsible for fulfillment of all Contract obligations. Beneficiaries: Except as herein specifically provided otherwise, this Contract shall inure to the benefit of and be binding upon the parties hereto and their respective successors. It is expressly understood and agreed that the enforcement of the terms and conditions of this Contract, and all rights of action relating to such enforcement, shall be strictly reserved to the Agency and the named Grantee. Nothing contained in this document shall give or allow any claim or right of action whatsoever by any other third person. It is the express intention of the Agency and Grantee that any such person or entity, other than the Agency or the Grantee, receiving services or benefits under this Contract shall be deemed an incidental beneficiary only. Indemnity Indemnification: The Grantee agrees to indemnify and hold harmless the Agency, including any of its Divisions, and any of its officers, agents and employees, from liability of any kind, and from any claims of third parties arising out of any act or omission of the Contractor in connection with the performance of this Contract to the extent permitted by law. Default and Termination Termination by Mutual Consent: The Parties may terminate this Contract by mutual consent with 60 days notice to the other party, or as otherwise provided by law. Termination for Cause: If, through any cause, the Grantee shall fail to fulfill its obligations under this Contract in a timely and proper manner, the Agency shall have the right to terminate this Contract by giving written notice to the Grantee and specifying the effective date thereof. In that event, all finished or unfinished deliverable items prepared by the Grantee under this Contract DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 PUBLIC SECTOR CONTRACTS (Including Local Governments) NCDA&CS - General Terms and Conditions – Public - Local Governmental Entities Eff. 07/14;4/15;1/17 Page 3 of 4 shall, at the option of the Agency, become its property and the Grantee shall be entitled to receive just and equitable compensation for any satisfactory work completed on such materials, minus any payment or compensation previously made. Notwithstanding the foregoing provision, the Grantee shall not be relieved of liability to the Agency for damages sustained by the Agency by virtue of the Grantee’s breach of this agreement, and the Agency may withhold any payment due the Grantee for the purpose of setoff until such time as the exact amount of damages due the Agency from such breach can be determined. The filing of a petition for bankruptcy by the Grantee shall be an act of default under this Contract. Waiver of Default: Waiver by the Agency of any default or breach in compliance with the terms of this Contract by the Grantee shall not be deemed a waiver of any subsequent default or breach and shall not be construed to be modification of the terms of this Contract unless stated to be such in writing, signed by an authorized representative of the Agency and the Grantee and attached to the Contract. Availability of Funds: The parties to this Contract agree and understand that the payment of the sums specified in this Contract is dependent and contingent upon and subject to the appropriation, allocation, and availability of funds for this purpose to the Agency. Force Majeure: Neither party shall be deemed to be in default of its obligations hereunder if and so long as it is prevented from performing such obligations by any act of war, hostile foreign action, nuclear explosion, riot, strikes, civil insurrection, earthquake, hurricane, tornado, or other catastrophic natural event or act of God. Survival of Promises: All promises, requirements, terms, conditions, provisions, representations, guarantees, and warranties contained herein shall survive the Contract expiration or termination date unless specifically provided otherwise herein, or unless superseded by applicable federal or State statutes of limitation. Intellectual Property Rights Copyrights and Ownership of Deliverables: All deliverable items produced pursuant to this Contract are the exclusive property of the Agency. The Grantee shall not assert a claim of copyright or other property interest in such deliverables. Compliance with Applicable Laws Compliance with Laws: The Grantee shall comply with all laws, ordinances, codes, rules, regulations, and licensing requirements that are applicable to the conduct of its business, including those of federal, State, and local agencies having jurisdiction and/or authority. Equal Employment Opportunity: The Grantee shall take affirmative action in complying with all federal and State statutes and all applicable requirements concerning fair employment of people with disabilities, and concerning the treatment of all employees without regard to discrimination by reason of race, color, religion, sex, national origin or disability. For additional information see Title VI of the Civil Rights Act of 1964 (42 U.S.C., 2000d, 2000e- 16), Title XI of the Education amendments of 1972, as amended (20 U.S.C. 1681-1683 and 1685-1686), and section 504 of the Rehabilitation Act of 1973 as amended (29 U.S.C. 794). Executive Order 24: In accordance with Executive Order 24, issued by Governor Perdue, and N.C.G.S.§ 133-32, a vendor or contractor (i.e. architect, bidder, contractor, construction manager, design professional, engineer, landlord, offeror, seller, subcontractor, supplier, vendor, or grantee), is prohibited from making gifts or giving favors to any employee of the Agency of Agriculture and Consumer Services. This prohibition covers those vendors , contractors, and/or grantees who: (a)have a Contract with a governmental Agency; or (b)have performed under such a Contract within the past year; or (c)anticipate bidding on such a Contract in the future. For additional information regarding the specific requirements and exemptions, vendors, contractors, and/or grantees are encouraged to review Executive Order 24 and N.C.G.S. § 133-32. Confidentiality Confidentiality: Any information, data, instruments, documents, studies or reports given to or prepared or assembled by the Grantee under this agreement shall be kept as confidential and not divulged or made available to any individual or organization without the prior written approval of the Agency. The Grantee acknowledges that in receiving, storing, processing or otherwise dealing with any confidential information it will safeguard and not further disclose the information except as otherwise provided in this Contract. Oversight Access to Persons and Records: The State Auditor and the using agency’s internal auditors shall have DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 PUBLIC SECTOR CONTRACTS (Including Local Governments) NCDA&CS - General Terms and Conditions – Public - Local Governmental Entities Eff. 07/14;4/15;1/17 Page 4 of 4 access to persons and records as a result of all Contracts or grants entered into by State agencies or political subdivisions in accordance with General Statute 147-64.7 and Session Law 2010-194, Section 21 (i.e., the State Auditors and internal auditors may audit the records of the contractor during the term of the Contract to verify accounts and data affecting fees or performance). Record Retention: Records shall not be destroyed, purged or disposed of without the express written consent of the Agency. State basic records retention policy requires all grant records to be retained for a minimum of five years or until all audit exceptions have been resolved, whichever is longer. If the Contract is subject to federal policy and regulations, record retention may be longer than five years since records must be retained for a period of three years following submission of the final Federal Financial Status Report, if applicable, or three years following the submission of a revised final Federal F inancial Status Report. Also, if any litigation, claim, negotiation, audit, disallowance action, or other action involving this Contract has been started before expiration of the five-year retention period described above, the records must be retained until completion of the action and resolution of all issues which arise from it, or until the end of the regular five-year period described above, whichever is later. Miscellaneous Choice of Law: The validity of this Contract and any of its terms or provisions, as well as the rights and duties of the parties to this Contract, are governed by the laws of North Carolina. The Grantee, by signing this Contract, agrees and submits, solely for matters concerning this Contract, to the exclusive jurisdiction of the courts of North Carolina and agrees, solely for such purpose, that the exclusive venue for any legal proceedings shall be Wake County, North Carolina. The place of this Contract and all transactions and agreements relating to it, and their situs and forum, shall be Wake County, North Carolina, where all matters whether sounding in Contract or tort, relating to the validity, construction, interpretation, and enforcement shall be determined. Headings: The Section and Paragraph headings in these General Terms and Conditions are not material parts of the agreement and should not be used to construe the meaning thereof. Time of the Essence: Time is of the essence in the performance of this Contract. Care of Property: The Grantee agrees that it shall be responsible for the proper custody and care of any property furnished to it for use in connection with the performance of this Contract and will reimburse the Agency for loss of, or damage to, such property. At the termination of this Contract, the Grantee shall contact the Agency for instructions as to the disposition of such property and shall comply with these instructions. Amendment: This Contract may not be amended orally or by performance. Any amendment must be made in written form and executed by duly authorized representatives of the Agency and the Grantee. Severability: In the event that a court of competent jurisdiction holds that a provision or requirement of this Contract violates any applicable law, each such provision or requirement shall continue to be enforced to the extent it is not in violation of law or is not otherwise unenforceable and all other provisions and requirements of this Contract shall remain in full force and effect. Travel Expenses: Reimbursement to the Grantee for travel mileage, meals, lodging and other travel expenses incurred in the performance of this Contract shall be reasonable and supported by documentation. State rates shall be used. International travel shall not be reimbursed under this Contract. Sales/Use Tax Refunds: If eligible, the Grantee and all subgrantees shall: (a) ask the North Carolina Department of Revenue for a refund of all sales and use taxes paid by them in the performance of this Contract, pursuant to G.S. 105-164.14; and (b) exclude all refundable sales and use taxes from all reportable expenditures before the expenses are entered in their reimbursement reports. Advertising: The Grantee shall not use the award of this Contract as a part of any news release or commercial advertising. Indirect Costs Policy: The Agency has adopted a “Zero” policy that indirect costs are unallowable expenditures in all State funded grant applications and/or grant guidance, informational or directional documents. Allowable Uses of State Funds: Expenditures of State funds by any grantee shall be in accordance with the Cost Principles outlined in the Office of Management and Budget (OMB) CFR Title 2, Part 200 Uniform Administrative Requirements, as applicable. If the grant funding includes federal sources, the grantee shall ensure adherence to the cost principles established by the Federal Office of Management and Budget. [09 NCAC 03M.020] DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 Certifications and Assurances NCDA&CS Certifications & Assurances Page 1 of 3 Rev 9/12, 10/12, 11/13;1/17 CERTIFICATIONS REGARDING LOBBYING, NONPROCUREMENT, DEBARMENT, SUSPENSION AND DRUG-FREE WORKPLACE Applicants should refer to the regulations cited below to determine the certification to which they are required to attest. Signature of this form provides for compliance with certification requirements under 2 CFR, Subtitle B, Chapter IV, Part 417, "Nonprocurement Debarment and Suspension," Part 418, "New Restrictions on Lobbying,” and Part 421, “Requirements for Drug-Free Workplace (Financial Assistance)," and 2 CFR Part 180. The certifications shall be treated as a material representation of fact upon which reliance will be placed when the Department of Agriculture & Consumer Services determines to award the covered transaction, grant, or cooperative agreement. 1. LOBBYING As required by authority: 31 U.S.C. 1352 and U.S.C. 301 and implemented at 2 CFR Part 180, for persons entering into a grant or cooperative agreement over $100,000, as defined at 2 CFR Section 418.110, the applicant certifies that to the best of their 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 an 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, the making of any Federal contract, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, 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 agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form -LLL, “Disclosure Form to Report Lobbying” in accordance with its instructions. 3)The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements) and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which r eliance was placed when 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 subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. 2.NONPROCUREMENT DEBARMENT AND SUSPENSION As required by Executive Order 12549, Debarment and Suspension, and implemented at 2 CFR Part 180 and 2CFR Part 417, for prospective participants in primary covered transactions, as defined at 2 CFR 180.435 and Subpart C, 417.332, the applicant certifies that it and its principals: a)Are not presently debarred, suspended, proposed for debarment, declared ineligible, or v oluntarily excluded from covered transactions by any Federal department or agency; b)Have not within a three-year period preceding this application been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, briber y, falsification or destruction of records, making false statements, or receiving stolen property; Attachment C DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 Page 2 of 3 NCDA&CS Certifications & Assurances Rev 9/12, 10/12, 11/13;1/17 c)Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph 2. (a) (b) of this certification. d)Have not within a three-year period preceding this application had o ne or more public transaction (Federal, State, or local) terminated for cause or default. e)Agree to include a term or condition in lower tier covered transactions requiring lower tier participants to comply with subpart C of the OMB guidance in 2 CFR part 180, as supplemen ted by subpart C of Part 417. Where the applicant is unable to certify to any of the statements in this certification, he or she shall attach an explanation to this certification. 3.DRUG-FREE WORKPLACE (GRANTEES OTHER THAN INDIVIDUALS) As required by the Drug-Free Workplace Act of 1988, and implemented at 2 CFR Part 182, Subparts B, and C, for grantees: The applicant certifies that it will: a)Make a good faith effort, on a continuing basis, to maintain a drug -free workplace. You must agree to do so as a condition for receiving any award covered by this part. b)Publish a drug-free workplace statement and establish a drug-free awareness program for your employees (see Sections 182.205 through 182.220); and c)Take actions concerning employees who are convicted of violating drug statutes in the w orkplace (see Section 182.225), including notification to any Fe deral agency on whose award the convicted employee was working and within 30 days take appropriate personnel action against the employee, up to and including termination, consistent with the requirements of the Rehabilitation Act of 1973 (29 U.S.C. 794), as amended; or require the employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for these purposes by a Federal, State or local health, law enforcement, or other appropriate agency. d)You must identify all known workplaces under your Federal awards (see Section 182.230). The grantee must provide the location site(s) for the performance of work done in connection with t he specific grant. Place(s) of Performance (Street address, city, county, state, zip code) DRUG-FREE WORKPLACE (GRANTEES WHO ARE INDIVIDUALS) As required by the Drug-Free Workplace Act of 1988, and implemented at 2 CFR Part 182: A.As a condition of the grant, I certify that I will comply with drug-free workplace requirements in Subpart B (or Subpart C, if the recipient is an individual) of part 421, which adopts the Government - wide implementation (2 CFR part 182) of sec. 5152-5158 of the Drug Free Workplace Act of 1988 (Pub.L100-690, Title V, Subtitle D; 41 U.S.C. 701-707). Bonnie B Davis Agricultural and Environment Building 1020 US 70 West Hillsborough, NC 27278 DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 NCDA&CS Certifications & Assurances Page 3 of 3 Rev 9/12, 10/12, 11/13;1/17 B.I agree to notify the agency as required by 2 CFR 182.300(b) of any conviction for a criminal drug offense within ten days. Notice shall include the identification number(s) of each affected grant. As the duly authorized representative of the Grantee, I hereby certify and state to the best of my knowledge and belief, that the Grantee will comply with the above certifications. Grantee Organization Name Signature of Authorized Representative Date Printed Name of Authorized Representative Title Orange County, a local body politic Bonnie B. Hammersley County Manager DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 11/15/2023 NC OpenBook Supplemental Information Page 1 of 1NCDA&CS NC OpenBook Supplemental Information Rev 07/14; 4/17; 5/22 Instructions: Complete the information below and return it to the Contract Administrator identified in your original contract. This information must be submitted as part of your contract. If you have questions, please contact the Contract Administrator or the Alternate Contact as reflected in your contract. Grantee Name: County of Residence: District Number (MUST BE FILLED IN): Tax Id Number: UEI Number**: I have started the UEI process but not received a UEI number. *Due to the SAM.gov migration from DU& Bradstreet, obtaining a UEI number has created unforeseen issues with the SAM.gov website search engines and portals. Due to the massive backlog in validation ticket issues, we are not requiring the UEI numbers at this time; however, if you have started the process, please let us know OR if you UEI number please provide it. Fiscal Year End: (MM/DD) Format Grantee’s Website: Current project timeline: Begin date End Date Attachment D Expected outcomes and specific deliverables: Expected outcome is intended result of your grant program. The specific deliverables are the accomplishments that will be achieved with the grant. EXAMPLE: Funding for the Farmers Produce Box program will allow an additional 150 boxes to be created this year. This will allow approximately 37 additional families to receive these the boxes 4 times a week to help resolve their food insecurity. MAX CHARACTERS: 300 **If your answer is Regional, list all Counties that are receiving benefit: Project Location Benefit Information: (Location(s) in which funding will be spent and/or food commodities will be received.) Single County Regional** Mountains Piedmont Inner Coastal Plain Tidewater Statewide GRANTEE INFORMATION: PROJECT INFORMATION: Brief Description and Background/History of your Organization: Be sure to include the number of years in existence, number of employees, mission and goals of your organization. MAX CHARACTERS: 250 Orange County Orange County 566000327 GFFMCW9XDA53 06/30 https://www.orangecountync.gov/ Lands Legacy Program of Orange County, 23 years. Two employees, one FT, one PT. A comprehensive program for the acquisition of protection of highly important natural and cultural resource lands in Orange County. This project will encourage the preservation of qualifying farmland and foster the growth, development, and sustainability of family farms in North Carolina. October 1, 2022 September 30, 2024 4 DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 Signature Card Page 1 of 1 NCDA&CS - Signature Card – NGO & Governmental Rev 7/14; 1/17;11/17 CONTRACT & FINANCIAL DOCUMENTS INSTRUCTIONS: Please read and fill in the required information to the right of each field where applicable. Signatures must match the Contract signatures. In the event the affixed signature(s) are no longer valid, a revised form must be submitted prior to processing any contractual documents or submitting “Request for Payments” or any other financial documents. If more than two people will sign for the organization, this form may be duplicated. SECTION I. Date: Legal Applicant Organization/Agency Name: Federal Tax Identification Number: SECTION II. Certification: By affixing my signature below, I certify that person(s) identified are designated having legal authorization to sign on behalf of the organization named in Section I., above, for purposes of executing contractual documents and preparing, approving and executing all financial documents; including “Requests for Payments.” I understand the legal implications of any and all misrepresentation, which include but are not limited to defrauding the State of North Carolina, and certify that the person signing below has full authority to execute this Agreement on behalf of the named organization. NON-GOVERNMENTAL ORGANIZATIONS ONLY (Must match Contract signature) Board Chair, Executive Director, etc. Financial Representative, Treasurer, etc. Print Name & Title: Print Name & Title: Signature: Signature: GOVERNMENTAL ENTITIES (Must match Contract signature) Authorized Governmental Official Chief Fiscal Officer Print Name & Title: Print Name & Title: Signature: Signature: Attachment E Orange County 566000327 Bonnie Hammersley, County Manager Gary Donaldson, Chief Financial Officer DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 11/15/2023 NC Office of the State Controller (IRS Form W-9 will not be accepted in lieu of this form) *Denotes a Required Field STATE OF NORTH CAROLINA SUBSTITUTE W-9 FORM Request for Taxpayer Identification Number Please complete the “Modification to Existing Vendor Records” section below If there have been any changes to the following: Tax Identification Number (TIN), Legal Name, Business Name, Remittance Address Return to the NC State Agency from which you are requesting payment. Section 1– Taxpayer Identification Section 2 -Certification *1. Social Security Number (SSN), OR Employer Identification Number (EIN), OR Individual Taxpayer Identification Number (ITIN) *2. Please select the appropriate Taxpayer Identification Number (EIN, SSN, or ITIN) type and enter your 9-digit ID number. The U.S. Taxpayer Identification Number is being requested per U.S. Tax Law. Failure to provide this information in a timely manner could prevent or delay payment to you or require The State of NC to withhold 24% for backup withholding tax. *4. Legal Name (as shown on your income tax return):3. Dunn & Bradstreet Universal Numbering System (DUNS) (see instructions) 5. Business Name/DBA/Disregarded Entity Name, if different from Legal Name: Contact Information *6. Legal Address 7. Remittance Address (Location specifically used for payment that is different from Legal Address, if applicable) *Address Line 1: Address Line 1: Address Line 2: Address Line 2: *City *State *Zip (9 digit) City State Zip (9 digit) *County County *8. Contact Name: *9. Phone Number: 10. Fax Number: 11. Email Address: *12. Entity Type *13. Entity Classification 14. Exemptions (see instructions) Individual/Sole Proprietor/Single-member LLC C-Corporation S-Corporation Partnership Trust/Estate Other___________________________ Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ________ Note: Check the appropriate box in the line above for the tax classification of the single- member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. Exempt payee code (if any): Exemption from FATCA reporting code (if any): Under penalties of perjury, I certify that: 1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding because of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3.I am a U.S. citizen or other U.S. person (defined later in general instructions), and 4.The FATCA code(s) entered on this form (if any) indicting that I am exempt from FATCA reporting is correct. Certification instructions: Please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/): *Printed Name: *Printed Title: *Authorized U.S. Signature: * Date: Medical Services Legal/Attorney Services NC Local Govt Federal Govt NC State Agency Other Govt Other (specify) N/A Attachment FREV 01/2019 (PRESS THE TAB KEY TO ENTER EACH NUMBER) (DO NOT TYPE OR WRITE IN THIS FIELD) 5 6 6 0 0 0 3 2 7 Orange County P.O. Box 8181 Hillsborough NC 27278 Gary Donaldson 919-245-2453 gdonaldson@orangecountync.gov Local Governmentn Gary Donaldson n n Chief Financial Officer DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 11/15/2023 NC Office of the State Controller *Denotes a Required Field This form is to be completed by the vendor. STATE OF NORTH CAROLINA SUBSTITUTE W-9 FORM Modification to Existing Vendor Records This form is to be completed by the vendor if one or more of the following have changed: 1.Change of remittance address. 2.Change of Social Security Number (SSN), or Employer Identification Number (EIN), or Individual Taxpayer Identification Number (ITIN). 3.Change of Vendor Name. Please complete the applicable sections below. Section 1: CHANGE FROM: Remittance Address CHANGE TO: Remittance Address Section 2: *CHANGE FROM: SSN, or EIN, or ITIN *CHANGE TO: SSN, or EIN, or ITIN Section 3: CHANGE FROM: Vendor Name CHANGE TO: Vendor Name *Address Line 1: Address Line 2: *City *State *Zip (9 digit) *County *Address Line 1: Address Line 2: *City *State *Zip (9 digit) *County *Legal Name:*Legal Name: Business Name/DBA/Disregarded Entity Name, if different from Legal Name: Business Name/DBA/Disregarded Entity Name, if different from Legal Name: *Printed Name:*Printed Title: *Authorized U.S. Signature: *Date: NOTE: If you would like to receive your payments electronically, please complete the Vendor Electronic Payment Form (PRESS THE TAB KEY TO ENTER EACH NUMBER) (PRESS THE TAB KEY TO ENTER EACH NUMBER) DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 NC Office of the State Controller Substitute W-9 Instructions Page 1 General Instructions For General Instructions, please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/). Specific Instructions Section 1 -Taxpayer Identification 1.Taxpayer Identification Type. Check the type of identification number provided in box 2. 2.Taxpayer Identification Number (TIN). Enter taxpayer’s nine-digit Employer Identification Number (EIN), Social Security Number (SSN), or Individual Taxpayer Identification Number (ITIN) without dashes. Note: If an LLC has one owner, the LLC's default tax status is "disregarded entity". If an LLC has two owners, the LLC's default tax status is "partnership". If an LLC has elected to be taxed as a corporation, it must file IRS Form 2553 (S Corporation) or IRS Form 8832 (C Corporation). 3.Dunn and Bradstreet Universal Numbering System (DUNS). Vendors are requested to enter their DUNS number, if applicable. 4.Legal Name. Enter the legal name as registered with the IRS or Social Security Administration. In general, enter the name shown on your income tax return. Do not enter a Disregarded Entity Name on this line. 5.Business Name. Business, Disregarded Entity, trade, or DBA ("doing business as") name. Contact Information 6.Enter your Legal Address. 7.Enter your Remittance Address, if applicable. A Remittance Address is the location in which you or your entity receives business payments. 8.Enter the Contact Name. 9.Enter your Business Phone Number. 10.Enter your Fax Number, if applicable. 11.Enter your Email Address, if applicable. For clarification on IRS Guidelines, see www.irs.gov. 12.Entity Type. Select the appropriate entity type. 13.Entity Classification. Select the appropriate classification type. Exemptions If you are exempt from backup withholding and/or FATCA reporting, enter in the Exemptions box, any code(s) that may apply to you. See Exempt payee code and Exemption from FATCA reporting code below. 14.Exempt payee code. Generally, individuals (including sole proprietors) are not exempt from backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions. Note. If you are exempt from backup withholding, you should still complete this form to avoid possible erroneous backup withholding. The following codes identify payees that are exempt from backup withholding: 1 - An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2) 2 - The United States or any of its agencies or instrumentalities 3 - A state, the District of Columbia, a possession of the United States, or any of their political subdivisions, or instrumentalities 4 - A foreign government or any of its political subdivisions, agencies, or instrumentalities 5 - A corporation 6 - A dealer in securities or commodities required to register in the United States, the District of Columbia, or a possession of the United States 7 - A futures commission merchant registered with the Commodity Futures Trading Commission 8 - A real estate investment trust 9 - An entity registered at all times during the tax year under the Investment Company Act of 1940 10- A common trust fund operated by a bank under section 584(a) 11 - A financial institution 12 - A middleman known in the investment community as a nominee or custodian 13 - A trust exempt from tax under section 664 or described in section 4947. DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 NC Office of the State Controller Substitute W-9 Instructions Page 2 The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13. If the payment is for… THEN the payment is exempt for… Interest and dividend payments All exempt payees except for 7 Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012. Barter exchange transactions and patronage dividends Exempt payees 1 through 4 Payments over $600 required to be reported and direct sales over $5,000¹ Generally, exempt payees 1 through 5² Payments made in settlement of payment card or third party network transactions Exempt payees 1 through 4 ¹ See Form 1099-MISC, Miscellaneous Income, and its instructions. ² However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys' fees, gross proceeds paid to an attorney, and payments for services paid by a federal executive agency. Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A - An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37) B - The United States or any of its agencies or instrumentalities C - A state, the District of Columbia, a possession of the United States, or any of their political subdivisions or instrumentalities D - A corporation the stock of which is regularly traded on one or more established securities markets, as described in Reg. section 1.1472- 1(c)(1)(i) E - A corporation that is a member of the same expanded affiliated group as a corporation described in Reg. section 1.1472-1(c)(1)(i) F - A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state G - A real estate investment trust H - A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940 I - A common trust fund as defined in section 584(a) J - A bank as defined in section 581 K - A broker L - A trust exempt from tax under section 664 or described in section 4947(a)(1) M - A tax exempt trust under a section 403(b) plan or section 457(g) plan Section 2 - Certification To establish to the paying agency that your TIN is correct, you are not subject to backup withholding, or you are a U.S. person, or resident alien, sign the certification on NC Substitute Form W-9. You are being requested to sign by the State of North Carolina. For additional information please refer to the IRS Form W-9 located on the IRS Website (https://www.irs.gov/). DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 Revised May 2018 Office of the State Controller Return to: OSC Support Services Center Address: 1410 Mail Service Center Raleigh, NC 27699-1410 Email: osc.support.services@osc.nc.gov Telephone: 919-707-0795 Vendor Electronic Payment Form New Add Request Change/Update Existing Account Inactivate Existing Account *Denotes a required field The State of North Carolina offers payees the opportunity to receive payments electronically through U.S. based banks. In addition to having the funds deposited electronically, you will also receive remittance information by e-mail. We require you to submit a copy of a voided check, bank statement, or a letter from your bank for account verification. *TAX ID # or SSN *PAYEE NAME *REMITTANCE ADDRESS (AS PRINTED ON STREET SUITE/ROOM # YOUR INVOICE) CITY STATE ZIP CODE *CONTACT NAME & TITLE PHONE NUMBER NEW FINANCIAL INFORMATION *FINANCIAL INSTITUTION NAME: *NAME ON ACCOUNT: *NEW ROUTING NUMBER: *NEW ACCOUNT NUMBER: *ACCT TYPE: Checking Savings *REMIT E-MAIL ADDRESS New add requests MUST include contact information for the state agency with which you are doing business. *Agency Name:*Agency Contact Name: *Agency Contact Email Address:*Agency Contact Phone Number: PRIOR FINANCIAL INFORMATION (only required for updates) FINANCIAL INSTITUTION NAME: NAME ON ACCOUNT: ROUTING NUMBER: ACCOUNT NUMBER: ACCT TYPE: Checking Savings REMIT E-MAIL ADDRESS * ALL BOXES BELOW MUST BE REVIEWED AND CHECKED I acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, and the requirements of the Office of Foreign Assets Control (OFAC). I affirm the entire amount of the payment will not be transferred to a foreign bank account. I authorize the Office of the State Controller to initiate ACH payments, and if necessary, adjustments for any ACH payments in error, to the financial institution and account identified on the attached certification document. This authority will remain in effect until I, the vendor, cancel it in writing or the authority is terminated by the NC Office of the State Controller. I have attached a copy of a current voided check, current bank statement or included a bank letter on bank letterhead. *PRINT NAME:*DATE: *SIGNATURE:*PHONE NUMBER: No change (Or current information if no changes) Attachment G 5 6 6 0 0 0 3 2 7 Orange County, North Carolina PO Box 8181 Hillsborough NC 27278 Gary Donaldson 919-245-2453 Truist Bank Orange County, North Carolina 0 6 1 0 0 0 1 0 4 4 0 1 0 3 6 1 6 7 n NC Dept of Agriculture and Consumer Services Allison Rodriguez allison.rodriguez@ncagr.gov 919-707-3073 4 4 4 Gary Donaldson- CFO 919-245-2543 DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 11/15/2023 Revised May 2018 Instructions * Denotes a required field on the form 1.*Check the appropriate box at the top of the form: ▪New Add Request – Vendor would like to begin receiving payments via ACH. ▪Change/Update Existing Account – Vendor’s account number, routing number, or remittance email address has changed. ▪Inactivate Existing Account – Vendor no longer wants to receive pa yments via ACH. 2.*Enter the vendor’s Tax Identification Number or Social Security Number. 3.*Enter the Payee Name – The name of the person or business receiving payment. 4.*Enter the vendor’s remittance address. The remittance address is the address printed on your invoice where payments should be sent. 5.*Enter the vendor’s contact name, title, and phone number. 6.*Enter the vendor’s financial information: ▪Financial Institution Name – Name of the financial institution. ▪Name on Account – The account owner’s name. ▪Routing Number – Nine-digit number identifying the financial institution. ▪Account Number – The bank account number where the funds should be deposited. ▪Account Type – Is this a checking or savings account? Check the appropriate box. ▪Remit E-mail address - Enter the email address to which the remittance advices should be sent. 7.*For a new add request only, provide the following: ▪Agency Name – The state agency the vendor is doing business with. ▪Agency Contact Name – The vendor’s contact person name at the state agency. ▪Agency Contact Email Address – The contact person’s email address at the state agency. ▪Agency Contact Phone Number – The contact person’s phone number at the state agency. NOTE: New add requests MUST include contact information for the state agency with which you are doing business. 8.Prior Financial Information – this is required if the vendor’s bank account, routing number, or remittance email address has changed. ▪Financial Institution Name – Name of the financial institution. ▪Name on Account – The account owner’s name. ▪Routing Number – Nine-digit number identifying the financial institution. ▪Account Number – The bank account number where the funds should be deposited. ▪Account Type – Is this a checking or savings account? Check the appropriate box. ▪Remit E-mail address - Enter the email address to which the remittance advices should be sent. 9.*Review all the information in the 3 attestation boxes located above the signature area. All 3 boxes must be checked – otherwise the form will not be processed. 10.*Print Name – Print the name of the authorized signee on the form. *Date – Date of signature. *Signature – The authorized signee’s signature. *Phone Number – The authorized signee’s phone number. Return to: OSC Support Services Center Address: 1410 Mail Service Center Raleigh, NC 27699-1410 Email: osc.support.services@osc.nc.gov Please allow up to 30 days for processing. DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 August 28, 2020 DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869 Revised 06/21 ORANGE COUNTY—DEPARTMENT USE ONLY ______________________________________________________________________________ Party/Vendor Name: North Carolina Department of Agriculture and Consumer Services Party/Vendor Contact Person: N. David Smith Contact Phone: 919-707-3033 Party/Vendor Address: 1001 Mail Service Center City Raleigh State: NC Zip: 27699 Department: DEAPR Amount: $$189,645.15 Purpose: Annual Contract Update for NCADFP Grant Contract for matched funds in acquisition of Conservation Easement of Poteat Family Farms Budget Code(s): 61370035-899950-20006 Vendor # 25374 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type: (Check one) New Renewal Amendment Effective Date 11/15/2023 Approved by Board Yes No Agenda Date: 9/20/2022 --- For Section XIV. c. contracts only, Approved by Board in Current FY Budget Yes No 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: F8ACCDE8-686F-4083-B46D-486310D8A869 11/15/2023 11/15/2023 11/15/2023 11/15/2023