HomeMy WebLinkAboutOTHER-2025-030-Acceptance of the Sobriety Treatment and Recovery Teams (START) Grant with the North Carolina Department of Health and Human Servicess and approval of related budget amendment #8-B Docusign Envelope ID: 50585F21 -A738-4303-BD3F-60841076ED5E
Contract Number 00048145 / Page 1 of 30
GENERAL CONTRACT COVER
This contract is hereby entered into by and between the North Carolina Department of Health and
Human Services , Division of Social Services (the " Division " ) and Orange County (the " Grantee" )
with Grantee Tax ID 566000327 , Grantee FYE 6/30 ( referred to collectively as the " Parties" ) .
1 . Contract Documents :
This contract consists of the following documents , which are incorporated herein by reference :
(a ) This contract cover
(b) The General Terms and Conditions
(c) Scope of Work
(d ) Federal Pass-Through Requirements
(e) Performance Measures Chart
(f) The Line Item Budget
(g ) Federal Certifications
(h ) State Certification
Incorporated By Reference
The following documents are reference materials and are available by going to the following
website , Open Window
( https :Hopenwindow. ncdhhs . gov/index , aspx?pid = doc ReferenceDocuments ) .
(a ) Travel : Policies Governing Travel Related Expenses for Grantees
(b) General Statutes G . S . 143C6 NonState Entities Receiving State Funds
(c) Subchapter 03M Uniform Administration of State Grants
These documents constitute the entire agreement between the Parties and supersede all prior
oral or written statements or agreements .
2 . Precedence Among Contract Documents :
In the event of a conflict between or among the terms of the Contract Documents , the terms in the
Contract Document with the highest relative precedence shall prevail . The order of precedence
shall be the order of documents as listed in the contract document section , with the first-listed
document having the highest precedence and the last-listed document having the lowest
precedence . If there are multiple contract amendments , the most recent amendment shall have
the highest precedence and the oldest amendment shall have the lowest precedence .
3 . Effective Period :
This contract shall be effective on 3/ 1 /2025 and shall terminate on 9/30/2025 , with the option to
extend , if mutually agreed upon , through a written amendment as provided for in the General
Terms and Conditions .
4. Grantee ' s Duties :
The Grantee shall provide the services as described in the scope of work and in accordance with
the approved budget .
NCDHHS GCT1007 ( Contract) ( General ) ( Rev. 11 /1 / 15 ;4/24 )
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5. Division's Duties :
The Division shall pay the Grantee in the manner and in the amounts specified in the contract
documents . The total amount paid by the Division to the Grantee under this contract shall not
exceed $ 320 ,480 . This amount consists of $0 in State funds , $0 in Local funds, $0 in Other funds
and $320 ,480 in Federal funds.
The total contract amount is $320 ,480 .
Acct Budget/Fund AMU/ Year Federal State County/Local Other
RCC
:564000d15133402 24067 1 $320,480 .0 $0M $0.00 $0.00
/ 1331 00 0
6 . Conflict of Interest Policy:
The division has determined that this contract is not subject to N .C.G . S . 143C-6-22 & 23 .
7 . Grants :
The Grantee/Grantee has the responsibility to ensure that all sub-grantees, if any, provide all
information necessary to permit the Grantee/Grantee to comply with the standards set forth in this
contract.
NCDHHS GCT1007 (Contract) (General ) (Rev. 11 /1 /15;4/24 )
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8. Reporting Requirements :
Local governmental grantees funded by state or federal pass-through funds are subject to
N . C . G. S § 159-34 and must submit an audit report to the Local Government Commission
accordingly.
All Grantees funded by federal pass-through funds are also subject to reporting requirements in
the Code of Federal Regulations , 2CFR Part 200, Subpart D and F , including § 200.303 Internal
controls and §§ 200. 331 -333 Subrecipient Monitoring and Management. Grantees that receive an
amount equal to or greater than the applicable audit threshold in federal funds , either direct or
pass-through funds, must submit a single or program-specific audit prepared and completed in
accordance with Generally Accepted Government Auditing Standards (GAGAS ) , also known as a
Yellow Book audit. The audit must be submitted to the Federal Audit Clearinghouse within 9
months of the Grantee's fiscal year end. Note : If a federal audit is required , the state audit
requirements are met by submitting the required federal audit.
9. Payment Provisions :
Payment shall be made in accordance with the contract documents as described in the scope of
work .
10. Contract Administrators :
All notices permitted or required to be given by one Party to the other and all questions about the
contract from one Party to the other shall be addressed and delivered to the other Party's contract
administrator. The name, post office address, street address, telephone number, fax number, and
email address of the Parties' respective initial contract administrators are set out below. Either
Party may change the name , post office address, street address , telephone number, fax number,
or email address of its contract administrator by giving timely written notice to the other Party .
For the Division .
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Leshana Moore , Prevention Consultant II Leshana Moore , Prevention Consultant II
Division of Social Services Division of Social Services
235 McBryde East 235 McBryde East
Raleigh , NC 27603 Raleigh , NC 27603
Telephone : (919)-000-0000
Fax : ()--
Email : LESHANA. MOORE DHHS . NC . GOV
For the Grantee:
IF DELIVERED BY US POSTAL SERVICE IF DELIVERED BY ANY OTHER MEANS
Crystal M Wiese , Human Services Manager Crystal M Wiese, Human Services Manager
Orange County Orange County
300 West Tryon St 300 West Tryon St
Hillsborough , NC 27278 Hillsborough , NC 27278
Telephone : (919)-245-2767
Fax: ()--
Email : cmitchell@orangecountync.gov
NCDHHS GCT1007 (Contract) (General ) (Rev. 11 /1 /15;4/24 )
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11 . Supplementation of Expenditure of Public Funds :
The Grantee assures that funds received pursuant to this contract shall be used only to
supplement, not to supplant, the total amount of federal , state and local public funds that the
Grantee otherwise expends for contract services and related programs. Funds received under
this contract shall be used to provide additional public funding for such services ; the funds shall
not be used to reduce the Grantee's total expenditure of other public funds for such services.
12. Disbursements :
As a condition of this contract, the Grantee acknowledges and agrees to make disbursements in
accordance with the following requirements:
(a) Implement adequate internal controls over disbursements;
(b) Pre-audit all vouchers presented for payment to determine:
• Validity and accuracy of payment
• Payment due date
• Adequacy of documentation supporting payment
• Legality of disbursement
(c) Assure adequate control of signature stamps/plates ;
(d) Assure adequate control of negotiable instruments ; and
(e) Implement procedures to insure that account balance is solvent and reconcile the account
monthly.
13. Outsourcing to Other Countries :
The Grantee certifies that it has identified to the Division all jobs related to the contract that have
been outsourced to other countries , if any. The Grantee further agrees that it will not outsource
any such jobs during the term of this contract without providing notice to the Division .
14. Federal Certifications :
Individuals and Organizations receiving federal funds must ensure compliance with certain
certifications required by federal laws and regulations. The grantee is hereby complying with
Certifications regarding Nondiscrimination , Drug-Free Workplace Requirements , Environmental
Tobacco Smoke, Debarment, Suspension , Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions, and Lobbying . These assurances and certifications are accompanied by
a signature page and can be found in the Grantee's Managed Documents section of DHHS Open
Window. The signature page is to be signed by the grantee's authorized representative .
15. Signature Warranty:
The undersigned represent and warrant that they are authorized to bind their principals to the
terms of this agreement.
Signatures follow on next page
NCDHHS GCT1007 (Contract) (General ) (Rev. 11 /1 /15 ;4/24 )
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16 . Electronic Signatures :
The parties agree that this Contract may be executed by electronic signature and with equal
validity , authenticity , enforceability , and admissibility as a handwritten signature . Each party will
retain one fully executed copy of the Contract .
Orange County
DocuSigned by:
rra� S A4t1MA, 03 / 25 / 25 3 : 17 PM EDT
I � Ai1i s"4B4. . Date
Travis Myren County Manager
Printed Name Title
Division of Social Services , North Carolina Department of Health and Human Services
DocuSigned by:
�IStL 04 /09/ 25 2 : 48 PM EDT
MMP`rYed 8fgnature Date
Lisa cauley Division Director , Human services child , Family , and
Printed Name Title
NCDHHS GCT1007 ( Contract) ( General ) ( Rev . 11 / l / 15 ;4/24 )
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GENERAL TERMS AND CONDITIONS
Relationships of the Parties Default and Termination
Independent Contractor: The Grantee is and shall be Termination Without Cause: The Division may
deemed to be an independent contractor in the terminate this contract without cause by giving 30 days
performance of this contract and as such shall be wholly written notice to the Grantee.
responsible for the work to be performed and for the
supervision of its employees . The Grantee represents that Termination for Cause : If, through any cause, the
it has , or shall secure at its own expense , all personnel Grantee shall fail to fulfill its obligations under this contract
required in performing the services under this agreement. in a timely and proper manner, the Division shall have the
Such employees shall not be employees of, or have any right to terminate this contract by giving written notice to
individual contractual relationship with , the Division . the Grantee and specifying the effective date thereof. In
that event, all finished or unfinished deliverable items
Subcontracting : The Grantee shall not subcontract any prepared by the Grantee under this contract shall , at the
of the work contemplated under this contract without prior option of the Division , become its property and the
written approval from the Division . Any approved Grantee shall be entitled to receive just and equitable
subcontract shall be subject to all conditions of this compensation for any satisfactory work completed on
contract. Only the subcontractors or subgrantees such materials, minus any payment or compensation
specified in the contract documents are to be considered previously made . Notwithstanding the foregoing
approved upon award of the contract. The Division shall provision , the Grantee shall not be relieved of liability to
not be obligated to pay for any work performed by any the Division for damages sustained by the Division by
unapproved subcontractors or subgrantees. The Grantee virtue of the Grantee's breach of this agreement, and the
shall be responsible for the performance of all its Division may withhold any payment due the Grantee for
subcontractors/subgrantees . the purpose of setoff until such time as the exact amount
of damages due the Division from such breach can be
Assignment: No assignment of the Grantee's obligations determined . In case of default by the Grantee, without
or the Grantee's right to receive payment hereunder shall limiting any other remedies for breach available to it, the
be permitted . However, upon written request approved by Division may procure the contract services from other
the issuing purchasing authority, the State may : (a ) sources and hold the Grantee responsible for any excess
Forward the Grantee's payment check directly to any cost occasioned thereby. The filing of a petition for
person or entity designated by the Grantee , or (b) Include bankruptcy by the Grantee shall be an act of default under
any person or entity designated by Grantee as a joint this contract .
payee on the Grantee's payment check. In no event shall
such approval and action obligate the State to anyone Waiver of Default : Waiver by the Division of any default
other than the Grantee and the Grantee shall remain or breach in compliance with the terms of this contract by
responsible for fulfillment of all contract obligations . the Grantee shall not be deemed a waiver of any
subsequent default or breach and shall not be construed
Beneficiaries : Except as herein specifically provided to be modification of the terms of this contract unless
otherwise, this contract shall inure to the benefit of and be stated to be such in writing , signed by an authorized
binding upon the parties hereto and their respective representative of the Department and the Grantee and
successors . It is expressly understood and agreed that attached to the contract.
the enforcement of the terms and conditions of this
contract, and all rights of action relating to such Availability of Funds : The parties to this contract agree
enforcement, shall be strictly reserved to the Division and and understand that the payment of the sums specified in
the named Grantee . Nothing contained in this document this contract is dependent and contingent upon and
shall give or allow any claim or right of action whatsoever subject to the appropriation , allocation , and availability of
by any other third person . It is the express intention of the funds for this purpose to the Division .
Division and Grantee that any such person or entity, other
than the Division or the Grantee, receiving services or Force Majeure : Neither party shall be deemed to be in
benefits under this contract shall be deemed an incidental default of its obligations hereunder if and so long as it is
beneficiary only. prevented from performing such obligations by any act of
war, hostile foreign action , nuclear explosion, riot, strikes,
Indemnity and Insurance civil insurrection , earthquake , hurricane , tomado , or other
catastrophic natural event or act of God.
Indemnification : The Grantee agrees to indemnify and
hold harmless the Division , the State of North Carolina , Survival of Promises : All promises, requirements,
and any of their officers , agents and employees , from any terms, conditions, provisions, representations,
claims of third parties arising out of any act or omission of guarantees , and warranties contained herein shall survive
the Grantee in connection with the performance of this the contract expiration or termination date unless
contract to the extent permitted by law. specifically provided otherwise herein , or unless
NCDHHS TC1010 (General Terms and Conditions) ( Local Government) (Rev. 8/24)
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superseded by applicable Federal or State statutes of federal Office for Civil Rights (OCR) received by the
limitation . grantee .
Intellectual Property Rights Cost Borne by Grantee : If any applicable federal , state,
or local law, regulation , or rule requires the Division or the
Copyrights and Ownership of Deliverables : All Grantee to give affected persons written notice of a
deliverable items produced pursuant to this contract are security breach arising out of the Grantee' s performance
the exclusive property of the Division . The Grantee shall under this contract, the Grantee shall bear the cost of the
not assert a claim of copyright or other property interest in notice .
such deliverables.
Oversight
Compliance with Applicable Laws
Access to Persons and Records : The State Auditor
Compliance with Laws : The Grantee shall comply with shall have access to persons and records as a result of
all laws , ordinances, codes, rules, regulations, and all contracts or grants entered into by State agencies or
licensing requirements that are applicable to the conduct political subdivisions in accordance with General Statute
of its business , including those of federal , state, and local 147-64 .7 . Additionally, as the State funding authority, the
agencies having jurisdiction and/or authority. Department of Health and Human Services shall have
access to persons and records as a result of all contracts
Equal Employment Opportunity : The Grantee shall or grants entered into by State agencies or political
comply with all federal and State laws relating to equal subdivisions .
employment opportunity.
Record Retention : See schedule for record retention for
Health Insurance Portability and Accountability Act instructions on disposal timeframes.
( HIPAA) : The Grantee agrees that, if the Division (https://www. ncdhhs.gov/aboutladministrative-
determines that some or all of the activities within the offices/office-controller/records-retention)
scope of this contract are subject to the Health Insurance
Portability and Accountability Act of 1996 , P . L. 104-91 , as Miscellaneous
amended ("HIPAA" ), or its implementing regulations , it will
comply with the HIPAA requirements and will execute Choice of Law: The validity of this contract and any of its
such agreements and practices as the Division may terms or provisions, as well as the rights and duties of the
require to ensure compliance . parties to this contract , are governed by the laws of North
Carolina . The Grantee, by signing this contract, agrees
Confidentiality and submits , solely for matters concerning this Contract,
to the exclusive jurisdiction of the courts of North Carolina
Confidentiality : Any information , data , instruments , and agrees, solely for such purpose, that the exclusive
documents , studies or reports given to or prepared or venue for any legal proceedings shall be Wake County,
assembled by the Grantee under this agreement shall be North Carolina . The place of this contract and all
kept as confidential and not divulged or made available to transactions and agreements relating to it, and their situs
any individual or organization without the prior written and forum , shall be Wake County, North Carolina , where
approval of the Division . The Grantee acknowledges that all matters, whether sounding in contract or tort, relating
in receiving, storing , processing or otherwise dealing with to the validity, construction , interpretation , and
any confidential information it will safeguard and not enforcement shall be determined .
further disclose the information except as otherwise
provided in this contract. Amendment: This contract may not be amended orally or
by performance. Any amendment must be made in
Data Security : The Grantee shall adopt and apply data written form and executed by duly authorized
security standards and procedures that comply with all representatives of the Division and the Grantee . The
applicable federal , state, and local laws, regulations , and Purchase and Contract Divisions of the NC Department
rules . of Administration and the NC Department of Health and
Human Services shall give prior approval to any
Duty to Report : The Grantee shall report a suspected or amendment to a contract awarded through those offices.
confirmed security breach to the Division' s Contract
Administrator within twenty-four (24 ) hours after the Severability : In the event that a court of competent
breach is first discovered , provided that the Grantee shall jurisdiction holds that a provision or requirement of this
report a breach involving Social Security Administration contract violates any applicable law, each such provision
data or Internal Revenue Service data within one ( 1 ) hour or requirement shall continue to be enforced to the extent
after the breach is first discovered . During the it is not in violation of law or is not otherwise
performance of this contract, the grantee is to notify the unenforceable and all other provisions and requirements
Division contract administrator of any contact by the of this contract shall remain in full force and effect.
NCDHHS TC1010 (General Terms and Conditions) (Local Government) ( Rev. 8/24)
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Headings : The Section and Paragraph headings in these Division for loss of, or damage to , such property. At the
General Terms and Conditions are not material parts of termination of this contract, the Grantee shall contact the
the agreement and should not be used to construe the Division for instructions as to the disposition of such
meaning thereof. property and shall comply with these instructions .
Gender and Number: Masculine pronouns shall be read Travel Expenses : Reimbursement to the Grantee for
to include feminine pronouns and the singular of any word travel mileage , meals , lodging and other travel expenses
or phrase shall be read to include the plural and vice incurred in the performance of this contract shall not
versa . exceed the rates published in the applicable State rules
or approved local government travel policy . International
Time of the Essence : Time is of the essence in the travel shall not be reimbursed under this contract.
performance of this contract.
Sales/Use Tax Refunds : If eligible, the Grantee and all
Key Personnel : The Grantee shall not replace any of the subcontractor/subgrantees shall : (a) ask the North
key personnel assigned to the performance of this Carolina Department of Revenue for a refund of all sales
contract without the prior written approval of the Division . and use taxes paid by them in the performance of this
The term "key personnel' includes any and all persons contract, pursuant to G .S . 105-164 . 14 ; and (b) exclude all
identified as such in the contract documents and any refundable sales and use taxes from all reportable
other persons subsequently identified as key personnel expenditures before the expenses are entered in their
by the written agreement of the parties . reimbursement reports .
Care of Property: The Grantee agrees that it shall be Advertising : The Grantee shall not use the award of this
responsible for the proper custody and care of any contract as a part of any news release or commercial
property furnished to it for use in connection with the advertising .
performance of this contract and will reimburse the
NCDHHS TC1010 (General Terms and Conditions) (Local Government) (Rev. 8/24)
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SCOPE OF WORK
BACKGROUND
The Sobriety Treatment and Recovery Teams (START) model is a child welfare led intervention that has been
shown, when implemented with fidelity, to improve outcomes for both parents and children affected by child
maltreatment and parental substance use disorders (SUD) . START is an evidence-based child abuse and neglect
prevention service that serves families where substance use has created a safety risk to thew children.
The program targets such families with children from ages birth (0) through five (5) who become involved with
child protective services where it is determined that the parent' s substance use is the primary child safety-factor.
START is specifically designed to transform the system-of-care within and between child welfare agencies and
SUD treatment providers ; it also engages the judicial system and other family serving agencies . It includes a
complex amay of strategies such as peer mentor supports , quick access to intensive SUD treatment, cross-system
collaboration, intensive case management, and a family-centered approach.
Children and Family Futures (CFF) is the model purveyor, a twenty-five (25) year-old nonprofit that provides
consultation, training, technical assistance, strategic planning, and evaluation services that are focused on the
intersection of child welfare, substance use and mental disorder treatment, and court systems . CFF serves as the
headquarters for the National START Training and Technical Assistance (TTA) Program. CFF is the only entity
that can provide the training, technical assistance, and consultation required to implement the START model . No
other entity can train, certify, or otherwise approve teams or dyads to provide START services .
PURPOSE
The Grantee will work with the Division to implement the START program within the county. Ongoing technical
assistance (TA) , coaching, and consultation will be provided to child welfare leadership and font-line staff to
resolve implementation issues and barriers . CFF worked with the state to customize a package for consultation,
training, and technical assistance (TTA) for every stage of implementation, supporting site readiness, including
the development of partnerships between SUD treatment providers, the courts, and other factors . TA will be
delivered virtually in most instances, but some in-person TA is possible. TA for county leadership will be at Ieast
monthly for the first 6- 12 months and may decrease to quarterly based on implementation progress and need; TA
for frontline staff will be at least monthly once they are identified/liked.
A series of four START Foundations trainings will be provided by CFF to county leadership, frontline staff, and
community partners . Trainings may be virtual or in person. Virtual tramings will be hosted on the CFF Zoom
platform. CFF will work with the state and local START Steering Committees to determine the order and timing
of each training based on readiness, identification of staff, and preparedness to begin serving families .
• Foundations L Introduction to START — This six-hour training for chill welfare and treatment provider
leadership and community partners provides an overview of the National START Model and an
introduction to the Essential Components and Fidelity Standards. If available, social workers , family
mentors, service coordinators, and other START staff are encouraged to attend.
• Foundations II: Family Mentor Hiring and Supervision This six-hour training prepares local START
programs for the hiring and supervision of family mentors. Participants for this training include START
supervisors and managers. Note: Use of the processes outlined in the Family Mentor Hiring Guide, which
is reviewed dining this training, is a requirement for START implementation and ultimately certification.
This training will be provided early in the Installation phase to allow hiring to occur before the last
foundations training.
• Foundations III: Treatment Provider Strategies — This 6-hour training for child welfare and treatment
provider leadership and front-line staff will focus on treatment provider strategies within START that
support treatment and child welfare outcomes . This training is open to community partners.
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• Foundations IV: Child Welfare Practices — This 6-hour training supports fivont-line practice of the START
model, builds on the material from Foundations I and H and is required for newly formed START teams .
This training will be offered for each START team (supervisor, social worker, and family mentor) before
they begin to serve families . Child welfare management is encouraged to attend .
The goals of the training, coaching, and consultation are to:
• Ensure that the START model is fist understood and selected to match the capacity and readiness of each
site, adapted to the jurisdiction with the guidance of the TTA consultants, and then implemented with
fidelity .
• Reinforce and coordinate START implementation with related child welfare, court improvement efforts ,
and other initiatives in the jurisdiction.
• Build the capacity of leaders and practitioners to implement and suustaiin START independently following
consultation, training, and technical assistance.
• Support the development of a learning organization culture incorporating program evaluation principles ,
ongoing quality improvement, and data-driven decisions .
SCOPE OF WORK (PERFORMANCE REQUIREMENTS)
By September 2025 , the Grantee shall implement the START program into the county ' s Child Welfare Practice
for families with at least one child from ages birth (0) through five (5), and their siblings, who become involved
with child protective services due to the parent' s substance use. The Grantee shall use START model ' s strategies
of, peer mentor supports , coordination to intensive SUD treatment, intensive case management, while using a
family-centered approach. The expected outcomes once fully implemented and firmly established within a
community include :
• Ensure child safety; and
• Reduce entry into out-of--home care, keeping children in the home with the parents when safe and
possible ; and
• Achieve child permanency within the Adoptions and Safe Families Act (ASFA) timeframes, preferably
with one or both parents or, if that is not possible, with a relative; and
• Achieve parental sobriety in time to meet ASFA permanency timeframes ; and
• Reduce repeat child maltreatment and re-entry into out-of-home care; 'and
• Expand behavioral health system quality-of-care and service capacity as needed to effectively serve
families with parental substance use and child maltreatment issues ; and
• Improve collaboration to transform the system of service delivery between child welfare and SUD/mental
health treatment providers .
PERFORMANCE STANDARDS
The Grantee shall :
• Ensure participation and coordination with the Grantee and CFF for ongoing technical assistance (TA),
coaching, and consultation.
• Demonstrate a commitment to meaningful parent engagement and leadership opportunities .
• Promote racial equity, diversity and inclusion within the agency.
• As a part of Continuous Quality Improvement practice, encourage ongoing staff development.
• County DSS reporting systems shall be kept tip to date, for the data integrity via the DSS Data
Warehouse.
• Ensure Data reporting to CFF and the University Research Evaluator of outputs and outcomes for
monitoring the program implementation. Reports require the CLADS information for each child in a family
which receives START services . Necessary data points for collection, for evidenced model fidelity:
o County Staff participating in webinars, technical assistance and Foundations Trainings
o Number families referred to the START team
o Number of children and families served by the START team
o Number/percentage of parents who, dining their START services episode:
■ Receive timely substance use assessment and substance use services
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■ Enter recommended treatment
■ Achieve sobriety
■ Remain in the recommended treatment
■ Complete the recommended treatment
PERFOP,N ANCE MONITORING / QUALITY ASSURANCE PLAN
Required reporting:
Monthly:
• DSS - 1571 III Adnninnistrative Cost Report and general ledger/supporting documentation by the l0ffi of
each subsequent month, even if no costs are incurred
• Monthly reporting Addendums for data collection requested by CFF, University Research Evaluator and
the Division
Quarterly :
• Completed Performance Monitoring Repoli for narrative program documentation:
o by April 30, 2025 for the period of January 2025 through March 202 .5
o by July 31 , 2025 for the period of April 2025 through June 2025
o by October 31 , 2025 for the period of July 2025 through September 2025
Annually:
• Maintain an active record in the federal government ' s System for Award Management (SAM) . This
record shall be updated annually.
• Federal Funding Accountability and Transparency Act (FFATA) Data Reporting Requirement form due
with annual renewal materials .
REIMBURSEMENT
The Grantee shall submit via email one signed DSS - 1571 III (Administrative Costs Report) to the Program
Consultant by the 101' of each month for services provided in the prior month . Please note that the person
preparing the invoice shall be different from the person authorized to sign it. Failure to submit monthly reports
may delay receipt of reimbursement. The Division will have no obligation for payments based on expenditure
reports submitted later than 30 days after termination or expiration of the contract period. All payments are
contingent upon fiend availability.
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Federal Pass-Through Requirements
Grantee Name Orange County
Grantee UEI GFFMCW9XDA53
Federal Award Identification # FAIN B08T1083959
Federal Award Date ##/##/## 5117/21
ContractAmendment Start Date 3/1/25
Contract/Amendment End Date 9/30/25
Subaward Federal Amount for This Action $320,480
(Obligated)
Subaward Federal Amount Total (Obligated) $320,480
Subaward Project Description
To provide financial assistance to States and Territories to support projects
for the development and implementation of prevention, treatment and
rehabilitation activities directed to the diseases of alcohol and drug abuse.
Name of Federal Awarding Agency US Substance Abuse and Mental Health Services Administration Center for
Substance Abuse Treatment
Pass-Through Agency/Division NC Division of Social Services
Pass-Through Awarding Official Secretary Devdutta Sangvai
Assistance Listing # 93.959
Assistance Listing Title Substance Abuse Prevention & Treatment Block Grant
R&D No
Indirect Cost Rate (Award) N/A
Federal Award Identification # FAIN
Federal Award Date ##/##/##
Contract/Amendment Start Date
Contract/Amendment End Date
Subaward Federal Amount forThis Action
(Obligated)
Subaward Federal Amount Total (Obligated)
Subaward Project Description
Name of Federal Awarding Agency
Pass-Through Agency/Division
Pass-Through Awarding Official Secretary Devdutta Sangvai
Assistance Listing #
Assistance Listing Title
R&D No
Indirect Cost Rate (Award) Not Applicable
Add Page Reset Form
Docusign Envelope ID: 50585F21-A738-4303-BD3F-60841076ED5E
Contract Number 00048145 / Page 13 of 30
PERFORMANCE MEASURES CHART
The Department of Health and Human Services uses performance measures rubrics as a tool to
determine the success of a project and how well services and products are being delivered .
Together they enable the Department to gauge efficiency, determine progress toward desired
results and assess whether the Department is on track with meeting its goals. The Grantee shall
adhere to all the performance requirements/standards in the scope of work, including
performance measures in the performance measures chart below.
Measure Output Reporting Annual
Type Frequency
Measure Percentage of parents served by a START Team remaining in recommended
treatment per month
Budget Yeer 1 Trend Increase
Baseline 0
Value
Target Value 75%
Data Source University Research Evaluator
Collection University Research Evaluator will collect data via County Reports
Process and
Calculation
i lectiOn Monthly
Frequency
Measure Output Rep Annual
Type Frequer►cy ,
Measure Number of families referred to a START Team
804cget Year 1 Trend Increase
Baseline 0
Value
Target Value 15
Dota our University Research Evaluator
%Co(W University Research Evaluator will collect data via CFF Fidelity
Process and Monitoring and County Reports
Calculation
Performance Measures ( Rev. 4/12 ;4/24 )
Docusign Envelope ID: 50585F21 -A738-4303-BD3F-60841076ED5E
Contract Number 00048145 / Page 14 of 30
Collection Monthly
frequency
Measure Output Reporting Annual
Type Frequency`
Measure Number of children and families served by a START Team
Budget Year 1 Trend Increase
Baseiin-a 0
Value
Target value 15
Data Source University Research Evaluator
Collection University Research Evaluator will collect data via CFF Fidelity
Procesa - a d Monitoring and County Reports
Calculation
Collection Monthly
Frequency
Measure Output Reporting Annual
Type Frequency;
Measure Number of children who enter foster care whose parents were enrolled in START.
Burdgt Y+�ar 1 Trend Increase
1$aseiine 0
Value
Targetslalue 8
Data Source University Research Evaluator
Collection ' University Research Evaluator will collect data via the data
Process and warehouse
ca% lculation
%collect ort Monthly
frequenc% y
Performance Measures ( Rev. 4/12 ;4/24 )
Docusign Envelope ID: 50585F21-A738A303-BD3F-60841076ED5E
Contract Number 00048145 ! Page 15 of 30
Measure Output Reporting Annual
Type Ereyuericy
Measure Number of county staff participating in Virtual Trainings - Foundations 1 , 11 , III and
IV.
Budget Year 1 Trend Increase
Baseline 0
Value
Target Value 15
Data Source CFF Report and State Project Manager
.. .. . .. . .. . . ... . . . . .. . . . . ..: . . . . ..
.Collection CFF Report and State Project Manager
Process and
Calculation
Collection ! Monthly
t=requency
Measure Output RepQiting Annual
Type re ,
Measure Number of parents served by a START Team who enter recommended treatment
per month .
Budget Year 1 Trend Increase
Baseline 0
Value
Target Value 30
Data ;.Source University Research Evaluator will collect data via CFF Fidelity
Monitoring and County Reports
Collection University Research Evaluator will collect data via County Reports
Process ;and
Calculation
Collection Monthly
Frequency
Performance Measures ( Rev. 4/12 ;4/24 )
Docusign Envelope ID: 50585F21 -A738-4303-BD3F-60841076ED5E
Contract Number 00048145 / Page 16 of 30
Measure Output 'Reporting Annual
Type FtequencV
Measure Number of parents served by a START Team who receive timely substance use
assessments and substance use services as evidenced by following fidelity of the
model .
Budget Year 1 Tread Increase
Baseline 0
Value
Target Value 30
Data Zourcov University Research Evaluator
Collection University Research Evaluator will collect data via County Reports
Process and
Calculatlon'
Collection Monthly
Frequency
Measure Output Reporting Annual
Type Frequerl Y
Measure Number of county staff participating in Welcome Webinars once counties are
selected .
Budge# Year 1 Trend Increase
Baseline 0
value
Target Value % 10
pa" Source CFF Report and State Project Manager
Collection , CFF Report and State Project Manager
Process and
ColciulatioIq
Collecction Monthly
freg iency
Performance Measures ( Rev. 4/12 ;4/24 )
Docusign Envelope ID: 50585F21 -A738A303-BD3F-60841076ED5E
Contract Number 00048145 / Page 17 of 30
Measure Output Reporting Annual
Type Fr 4iiency
Measure Percentage of parents served by a START Team who achieve sobriety during their
START services episode .
BudgefYeer 1 Trend Increase
Baseline 0
Value
Target,Value 75%
Data,Soureb University Research Evaluator
Collection University Research Evaluator will collect data via County Reports
i'ro ess and
Calculation;
Collection Monthly
Frequency
Measure Output Ropvtting Annual
Type Fc�euency .
Measure Percentage of parents served by a START Team who complete recommended
treatment.
Budget Year 1 Trend Increase
Baseline 0
-Value
Target-Value 75%
Data `,Source University Research Evaluator
Collection University Research Evaluator will collect data via CFF Fidelity
Process And Monitoring and County Reports
:Calculation
Collection Monthly
Frequency
Performance Measures ( Rev. 4/12 ;4/24 )
Docusign Envelope ID: 50585F21 -A738A303-BD3F-60841076ED5E
Contract Number 00048145 / Page 18 of 30
Measure Outcome Reporting Annual
Type Frequency
Measure Sustained permanency of children at 6- and 12 months post-intervention .
Budget Year 1 Trend Increase
Baseline 0
Value
Target Value 23
Dais Source , University Research Evaluator
Collection University Research Evaluator will collect data via the data
Prtme' s %.and warehouse
' Calculation
Collection Monthly
Frequency
Measure Outcome Reporting Annual
Type Frequency
Measure Number of children who enter foster care and who are reunified for START
enrolled families.
Budget Ye4ir 1 Tread Increase
Baseline 0
Value
Target Value 15
DatarZource University Research Evaluator
Collect#ion University Research Evaluator will collect data via the data
Process and warehouse
calculation '
Collection Monthly
Fr0qui envy,
Performance Measures (Rev. 4/12 ;4/24)
Docusign Envelope ID: 50585F21-A73BA303-BD3F-60841076ED5E
Contract Number 00048145 / Page 19 of 30
Measure Outcome Reporting Annual
Type IFregluency
Measure Number of children who remain in the custody of the referred parent post START
team enrollment.
Budget Year 1 Trend Increase
"Baseline 0
1/alue.
Target Owe 23
Data Source University Research Evaluator
Collection University Research Evaluator will collect data via the data
Process `-and warehouse
Calculation
Collection Monthly
Frequency .
Measure Outcome Reporting Annual
Type Frequ%ency
Measure Percent of recurrence of repeat maltreatment of children at 6 and 12 months post-
intervention (non-START) .
Budget Year 1 Trend Increase
Baseline % 0
ltalue
Target value 75%
Data Source University Research Evaluator
Collection University Research Evaluator will collect data via the data
Process and warehouse
calculation
Collection Monthly
%% q
Performance Measures ( Rev. 4/12 ;4/24 )
Docusign Envelope ID: 50585F21-A73Bd3038D3F-60841076ED5E
Contract Number 00048145 / Page 20 of 30
LINE ITEM BUDGET
This begins the tine Item budget for year 1
Budget Detail - Year%,.9
Category Item Narrative Amount
Salary\Wages $0.00
Fringe Benefits $0.00
Other The START Program can reimburse up to the approved amounts $2801369.00
towards salaries and fringe for county employees or contracted
services for the Peer Specialists and Service Coordinator
positions. The total includes all salaries, FICA, Retirement or
401K, Health/Medical, Unemployment Insurance, Worker's Comp,
and other including, Bonus or Longevity Pay and Contractor fees.
Peer Specialist 1 $33,245 ($56,992 @ 7 months 100% _ $331245)2
Peer Specialist 2 $33,245 ($561992 @ 7 months 100% _ $33,245),
Service Coordinator $43,398 ($74,396 @ 7 months 100% =
$43,398). Clinical Supervisor $8,624 ($731920 @ 7 months 20% _
$8,624), CW Supervisor $51 ,899 ($1181625 @ 7 months 75% _
$51 )899)0 CW Social Worker 1 $54 ,979 ($94,250 @ 7 months
100% = $541979), CW Social Worker 2 $54 ,979 ($94,250 @ 7
months 100% _ $54,979),Total ($33,245+ $33,245 + $43,398 +
$8 ,624 + $51 ,899 + $54,979 + $54979, _ $280,369
Supplies and Materials Other Routine Office Supplies for two Peer Specialists and one Service $21250,00
Coordinator for 7 months of START Program $750 for each
position. Total ($750 x 3 = $2,250)
Equipment IT Laptop $1 ,200 ($1 ,200 x 3 = $3,600), Monitors and IT Accessories $5T400.00
$600 ($600 x 3 = $ 1 ,800), one each for the two Peer Specialist
and one for the Service Coordinator. Total ($3,600 + $ 17800 =
Line Item Budget Detail (08/11 )
Docuwgn Envelope ID: 50585F21-A7384303-BD3F-60841076ED5E
Contract Number 00048145 / Page 21 of 30
-13ufget Detaill Year
Category Item Narrative Amount
%$51400)
Equipment Communication Cell Phone $700, one for each for two Peer Specialist and one for $2, 100,00
the Service Coordinator. Total (700 x 3 = $2, 100)
Travel Grantee Staff Travel for two Peer Specialists and one Service Coordinator — $81967.00
Mileage: Expected meetings, visits and travel around county
average 300 miles per month X $0.67 or federal reimbursement
rate (500 X 0.67 = $335 x 7 months = $2345 x 3 = $7,035) Note:
Any mileage charged to this contract must meet the requirements
of current IRS established rate and Section 5. 1 .26 of the NC
OSBM Budget Manual. Lodging : Average 4 nights lodging and
meal per diem ($ 107 x 4) _ $428, ($54.00 x 4) _ $216.00, $428 +
$216,00 = $644 x 3 = $1932. Total ($7,035 + $ 1 ,932 = $8,967)
Utilities Telephone Cell Phone Service $65 monthly, for 7 months, one for each of the $ 1 ,365.00
two Peer Specialist and one for the Service Coordinator. Total
($65 x 7 = 455) x 3 = $ 1 ,365)
Repair and Maintenance $0.00
Staff Development Conference Registration $243, for the two Peer Specialists and $3,929.00
one Service Coordinator. Subtotal: ($243 x 3 = $729) Training for
six staff in Motivational Interviewing: $200 each ($200 x 6 =
$ 1 ,200) Training for staff in North Carolina Certified Peer Support
Specialist Program (NCCPSS) for two Peer Specialists: $11000
each Specialist ($1 ,000 x 2 = $2,000) Total ($1 ,200 + $2,000 =
$3,200)
Total: $3,200 + $729= $3,929
Dues and Subscriptions $0.00
Line Item Budget Detail (08111 )
Docusign Envelope ID: 50565F21-A738d303BD3F-60841076ED5E
Contract Number 000481451 Page 22 of 30
Budget Detail - Year, 1
Category item Narrative ' Amount
Operational Other Not Otherwise Classified Drug screens reimbursement, up to $1 ,500. Average of 100 per $1 ,500,00
year / $15.00 each. Total (100 x $15 = $11500)
Operational Other Not Otherwise Classified Substance Use Disorder Assessment reimbursement, up to $600. $600,00
Average 2 per year 1 $300 Total (2 x $300 = $600)
Operational Other Not Otherwise Classified Treatment Services reimbursement, up to $14,000 includes $14,000,00
uncoveredluninsured treatments, (For uncovered treatments,
assume 10% Uninsured/Unable to access State funded (Medicaid)
Services) Total $ 14 ,000
Subcontracts and Grants $0,00
Match $0,00
Cost Per Service $0,00
Sub Tota) ! $3201480.00
Indirect Cost $0.00
Totet Budget $320,480,00
Subi %oriiraci ing aci% d Grants 8i;ojot Detail -^Yeiie I
Category Iterrr Na, "rrative Amount
Line Item Budget Detail (08/11 )
Docusign Envelope ID: 50585F21-A738d303-BD3F-60841076ED5E
Contract Number 00048145 / Page 23 of 30
SubeQntractIw;rld Grants Budget Det4i1 -Year 1
Category stern iVarra#ive Amount
$0.00
Sub Total $0.00
Salaries % " Year I
ro" Isons Positlgn (it T%,4* �Anmal Salary Hourly, , Months w6* fir 0" rig9e TQtille
Rate Amount Total OereentTetal
%
0 $0.00 0.0000 0 0% $0.00 $0.00 $0.00
Line Item Budget Detail (08/11 )
Docusign Envelope ID: 50585F21-A738-4303-BD3F-60841076ED5E
FEDERAL CERTIFICATIONS Contract Number 00048145 / Page 24 of 30
The undersigned states that :
1 . He or she is the duly authorized representative of the Grantee named below;
2 . He or she is authorized to make, and does hereby make , the following certifications on behalf of the Grantee, as set out
herein :
a . The Certification Regarding Nondiscrimination ;
b . The Certification Regarding Drug-Free Workplace Requirements ;
c. The Certification Regarding Environmental Tobacco Smoke;
d . The Certification Regarding Debarment, Suspension , Ineligibility and Voluntary Exclusion Lower Tier Covered
Transactions ; and
e. The Certification Regarding Lobbying ;
3. He or she has completed the Certification Regarding Drug-Free Workplace Requirements by providing the addresses
at which the contract work will be performed ;
4 . [Check the applicable statement]
[ ] He or she has completed the attached Disclosure Of Lobbying Activities because the Grantee has made, or
has an agreement to make , a payment to a lobbying entity 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 a covered Federal action ;
OR
[X] He or she has not completed the attached Disclosure Of Lobbying Activities because the Grantee has not
made , and has no agreement to make , any payment to any lobbying entity for influencing or attempting to
influence any officer or employee of any agency, any Member of Congress, any officer or employee of Congress,
or any employee of a Member of Congress in connection with a covered Federal action .
5. The Grantee shall require its subcontractors/subgrantees , if any, to make the same certifications and disclosure .
DocuSigncd by:
r W4111111 Ion
County Mana er
Signature Title
1/ 16/2025
Orange County NC
Grantee Name Date
[This Certification Must be Signed by the Same Individual Who Signed the Proposal Execution Page]
I . Certification Regarding Nondiscrimination
The Grantee certifies that it will comply with all Federal statutes relating to nondiscrimination . These include but are not
limited to: (a) Title VI of the Civil Rights Act of 1964 (POLO 88-352) which prohibits discrimination on the basis of race , color
or national origin ; (b) Title IX of the Education Amendments of 1972, as amended (20 U .S .C . §§ 1681 Owl 683 , and 1685-1686) ,
which prohibits discrimination on the basis of sex; (c) Section 504 of the Rehabilitation Act of 1973, as amended (29 U . S . C .
§794), which prohibits discrimination on the basis of handicaps; (d ) the Age Discrimination Act of 1975, as amended (42
U .S .C . §§61010*6107), which prohibits discrimination on the basis of age; (e) the Drug Abuse Office and Treatment Act of
1972 ( POLO 92-255) , as amended , relating to nondiscrimination on the basis of drug abuse ; (f) the Comprehensive Alcohol
Abuse and Alcoholism Prevention , Treatment and Rehabilitation Act of 1970 (POLO 91 -616 ), as amended , relating to
nondiscrimination on the basis of alcohol abuse or alcoholism ; (g ) Title Vill of the Civil Rights Act of 1968 (42 U . S. C . §§3601
et seq . ) , as amended, relating to nondiscrimination in the sale , rental or financing of housing ; (h ) the Food Stamp Act and
USDA policy, which prohibit discrimination on the basis of religion and political beliefs; and (i ) the requirements of any other
nondiscrimination statutes which may apply to this Agreement .
Docusign Envelope ID: 50585F21-A7384303-BD3F-60841076ED5E
Contract Number 00048145 / Page 25 of 30
II . Certification Regarding Drug -Free Workplace Requirements
1 . The Grantee certifies that it will provide a drug-free workplace by:
a . Publishing a statement notifying employees that the unlawful manufacture, distribution , dispensing , possession or
use of a controlled substance is prohibited in the Grantee's workplace and specifying the actions that will be taken
against employees for violation of such prohibition ;
b. Establishing a drug-free awareness program to inform employees about:
i . The dangers of drug abuse in the workplace;
ii . The Grantee's policy of maintaining a drug-free workplace;
His Any available drug counseling , rehabilitation , and employee assistance programs; and
iv. The penalties that may be imposed upon employees for drug abuse violations occurring in the workplace ;
c. Making it a requirement that each employee be engaged in the performance of the agreement be given a copy of
the statement required by paragraph (a);
d . Notifying the employee in the statement required by paragraph (a) that, as a condition of employment under the
agreement, the employee will :
i . Abide by the terms of the statement; and
ii . Notify the employer of any criminal drug statute conviction for a violation occurring in the workplace no later
than five days after such conviction ;
e. Notifying the Department within ten days after receiving notice under subparagraph (d)( ii ) from an employee or
otherwise receiving actual notice of such conviction ;
f. Taking one of the following actions , within 30 days of receiving notice under subparagraph (d)(ii ) , with respect to
any employee who is so convicted:
i . Taking appropriate personnel action against such an employee, up to and including
termination ; or
ii . Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program
approved for such purposes by a Federal, State, or local health , law enforcement, or other appropriate
agency; and
g . Making a good faith effort to continue to maintain a drug-free workplace through implementation of paragraphs
(a), (b), (c) , (d) , (e) , and (f) .
2. The sites for the performance of work done in connection with the specific agreement are listed below (list all sites;
add additional pages if necessary) :
Address
Street
113 Mayo Street
City, State, Zip Code
Hillsborough NC 27278
Street
2501 Homestead Road
City, State , Zip Code
Chapel Hill NC 27516
Docusign Envelope ID: 50585F21-A738-4303-BD3F-60841076ED5E
3 . Grantee will inform the Department of any additional sites for performance of wor trunder Iiiseagreem8ent5 / Page 26 of 30
4. False certification or violation of the certification may be grounds for suspension of payment, suspension or termination
of grants, or government-wide Federal suspension or debarment. 45 C . F . R . 8205100
III . Certification Regarding Environmental Tobacco Smoke
Public Law 103-227 , Part C-Environmental Tobacco Smoke , also known as the Pro-Children Act of 1994 (Act), requires
that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and used
routinely or regularly for the provision of health, day care, education , or library services to children under the age of 18, if
the services are funded by Federal programs either directly or through State or local governments, by Federal grant,
contract, loan , or loan guarantee . The law does not apply to children's services provided in private residences, facilities
funded solely by Medicare or Medicaid funds , and portions of facilities used for inpatient drug or alcohol treatment. Failure
to comply with the provisions of the law may result in the imposition of a civil monetary penalty of up to $ 1 ,000. 00 per day
and/or the imposition of an administrative compliance order on the responsible entity.
The Grantee certifies that it will comply with the requirements of the Act. The Grantee further agrees that it will require the
language of this certification be included in any subawards that contain provisions for children's services and that all
subgrantees shall certify accordingly.
IV. Certification Regarding Debarment, Suspension , Ineligibility and Voluntary Exclusion Lower Tier
Covered Transactions
Instructions
[The phrase "prospective lower tier participant" means the Grantee .]
1 . By signing and submitting this document, the prospective lower tier participant is providing the certification set out below.
2 . The certification in this clause is a material representation of the fact upon which reliance was placed when this
transaction was entered into . If it is later determined that the prospective lower tier participant knowingly rendered an
erroneous certification , in addition to other remedies available to the Federal Government , the department or agency
with which this transaction originate may pursue available remedies , including suspension and/or debarment.
3 . The prospective lower tier participant will provide immediate written notice to the person to whom this proposal is
submitted if at any time the prospective lower tier participant learns that its certification was erroneous when submitted
or has become erroneous by reason of changed circumstances.
4 . The terms "covered transaction , " "debarred , " "suspended," "ineligible," "lower tier covered transaction ," "participant, "
"person , " "primary covered transaction , " "principal ," "proposal ," and "voluntarily excluded, " as used in this clause , have
the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order 12549, 45 CFR
Part 76 . You may contact the person to whom this proposal is submitted for assistance in obtaining a copy of those
regulations .
5 . The prospective lower tier participant agrees by submitting this proposal that, should the proposed covered transaction
be entered into, it shall not knowingly enter any lower tier covered transaction with a person who is debarred , suspended,
determined ineligible or voluntarily excluded from participation in this covered transaction unless authorized by the
department or agency with which this transaction originated .
6. The prospective lower tier participant further agrees by submitting this document that it will include the clause titled
"Certification Regarding Debarment, Suspension , Ineligibility and Voluntary Exclusion --Lower Tier Covered
Transaction , " without modification , in all lower tier covered transactions and in all solicitations for lower tier covered
transactions.
7 . A participant in a covered transaction may rely upon a certification of a prospective participant in a lower tier covered
transaction that it is not debarred , suspended , ineligible, or voluntarily excluded from covered transaction , unless it
knows that the certification is erroneous . A participant may decide the method and frequency by which it determines the
eligibility of its principals. Each participant may, but is not required to, check the Nonprocurement List.
Docusign Envelope ID: 50585F21-A738-4303-BD3F-60841076ED5E
8 . Nothing contained in the foregoing shall be construed to require establishment of a systeNumber
of recorOd4 in4orderato rne ender
in in good faith the certification required by this clause . The knowledge and information of a participant is not required to
exceed that which is normally possessed by a prudent person in the ordinary course of business dealings .
9 . Except for transactions authorized in paragraph 5 of these instructions , if a participant in a covered transaction knowingly
enters into a lower tier covered transaction with a person who is suspended , debarred , ineligible , or voluntarily excluded
from participation in this transaction , in addition to other remedies available to the Federal Government, the department
or agency with which this transaction originated may pursue available remedies , including suspension , and/or
debarment.
Certification
1 . The prospective lower tier participant certifies , by submission of this document, that neither it nor its principals is
presently debarred , suspended , proposed for debarment, declared ineligible, or voluntarily excluded from participation
in this transaction by any Federal department or agency.
2 . Where the prospective lower tier participant is unable to certify to any of the statements in this certification , such
prospective participant shall attach an explanation to this proposal.
V. Certification Regarding Lobbying
The Grantee certifies , to the best of his or her knowledge and belief, that:
1 . No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned , to any person for
influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or
employee of Congress , or an employee of a Member of Congress in connection with the awarding of any Federal
contract, continuation , renewal , amendment, or modification of any Federal contract, grant, loan , or cooperative
agreement.
2 . If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of
Congress, or an employee of a Member of Congress in connection with this Federally funded contract, grant, loan , or
cooperative agreement, the undersigned shall complete and submit Standard Form SF-LLL, 'Disclosure of Lobbying
Activities , " in accordance with its instructions.
3 . The undersigned shall require that the language of this certification be included in the award document for subawards
at all tiers (including subcontracts , subgrants , and contracts under grants, loans , and cooperative agreements ) who
receive federal funds of $ 100, 000 . 00 or more and that all subrecipients shall certify and disclose accordingly.
4. This certification is a material representation of fact upon which reliance was placed 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 .00 and not more than $ 100 , 000 .00 for each such failure.
VI . Disclosure Of Lobbying Activities
Instructions
This disclosure form shall be completed by the reporting entity, whether subawardee or prime Federal recipient, at the
initiation or receipt of a covered Federal action , or a material change to a previous filing , pursuant to title 31 U .S. C. section
1352 . The filing of a form is required for each payment or agreement to make payment to any lobbying entity for influencing
or attempting to influence an officer or employee of any agency, a Member of Congress , an officer or employee of Congress,
or an employee of a Member of Congress in connection with a covered Federal action . Use the SF-LLL-A Continuation
Sheet for additional information if the space on the form is inadequate. Complete all items that apply for both the initial filing
and material change report . Refer to the implementing guidance published by the Office of Management and Budget for
additional information .
Docusign Envelope ID: 50585F21 -A73"303-BD3F-60841076ED5E
Identify the type of covered Federal action for which lobbying activity is and/or has eeencsecured toQ�fluence �headtataomoe 30
of a covered Federal action .
1 . Identify the status of the covered Federal action .
2 . Identify the appropriate classification of this report. If this is a follow-up report caused by a material change to the
information previously reported , enter the year and quarter in which the change occurred. Enter the date of the last
previously submitted report by this reporting entity for this covered Federal action .
3 . Enter the full name, address , city, state and zip code of the reporting entity. Include Congressional District, if known .
Check the appropriate classification of the reporting entity that designates if it is, or expects to be, a prime or sub-award
recipient. Identify the tier of the subawardee , e .g . , the first subawardee of the prime is the 1st tier. Subawards include
but are not limited to subcontracts , subgrants and contract awards under grants .
4. If the organization filing the report in Item 4 checks "Subawardee", then enter the full name , address , city, state and zip
code of the prime Federal recipient. Include Congressional District, if known .
5 . Enter the name of the Federal agency making the award or loan commitment. Include at least one organizational level
below agency name, if known . For example, Department of Transportation , United States Coast Guard .
6 . Enter the Federal program name or description for the covered Federal action ( Item 1 ). If known , enter the full Catalog
of Federal Domestic Assistance (CFDA) number for grants , cooperative agreements , loans, and loan commitments .
7 . Enter the most appropriate Federal Identifying number available for the Federal action identified in Item 1 (e . g . , Request
for Proposal ( RFP) number, Invitation for Bid ( IFB) number, grant announcement number, the contract grant, or loan
award number, the application/proposal control number assigned by the Federal agency). Include prefixes, e.g . , " RFP -
D &90-001 . "
8 . For a covered Federal action where there has been an award or loan commitment by the Federal agency, enter the
Federal amount of the award/loan commitment for the prime entity identified in Item 4 or 5 .
9 . (a) Enter the full name , address, city, state and zip code of the lobbying entity engaged by the reporting entity identified
in Item 4 to influence the covered Federal action .
(b ) Enter the full names of the individual (s) performing services and include full address if different from 10(a) . Enter
Last Name , First Name and Middle Initial (MI ).
10. Enter the amount of compensation paid or reasonably expected to be paid by the reporting entity ( Item 4) to the lobbying
entity ( Item 10). Indicate whether the payment has been made (actual ) or will be made (planned ). Check all boxes that
apply. If this is a material change report, enter the cumulative amount of payment made or planned to be made.
11 . Check the appropriate boxes . Check all boxes that apply. If payment is made through an in -kind contribution , specify
the nature and value of the in-kind payment.
12 . Check the appropriate boxes . Check all boxes that apply. If other, specify nature .
13 . Provide a specific and detailed description of the services that the lobbyist has performed , or will be expected to perform,
and the date(s) of any services rendered . Include all preparatory and related activity, not just time spent in actual contact
with Federal officials. Identify the Federal official (s ) or employee(s ) contacted or the officer(s) , employee(s) , or
Member(s) of Congress that were contacted .
14. Check whether or not a SF- LLL-A Continuation Sheet(s) is attached .
15 . The certifying official shall sign and date the form , print his/her name , title , and telephone number.
Public reporting burden for this collection of information is estimated to average 30 minutes per response , including time
for reviewing instructions , searching existing data sources, gathering and maintaining the data needed , and completing
and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of this
collection of information , including suggestions for reducing this burden , to the Office of Management and Budget,
Paperwork Reduction Project 0348-0046 , Washington , D . Co 20503
Docusign Envelope ID: 50585F21 -A738-4303-BD3F-60841076ED5E
Disclosure Of Lobbying Activities Contract Number 00048145 / Page 29 of 30
(Approved by OMB 0344=0046)
Complete this form to disclose lobbying activities pursuant to 31 U.S . C . 1352
1 . Type of Federal Action: 2. Status of Federal Action : 3. Report Type:
❑ a. contract ❑ a. Bid/offer/application ❑ a. initial filing
❑ b. grant ❑ b. Initial Award ❑ b . material change
❑ c. cooperative agreement ❑ c. Post-Award
❑ d. loan For Material Change Only:
❑ e. loan guarantee
❑ f. loan insurance Year Quarter
Date Of Last Report:
4 . Name and Address of Reporting Entity: 5 . If Reporting Entity in No. 4 is Subawardee , Enter Name
and Address of Prime:
❑ Prime
❑ Subawardee Tier (if known)
Congressional District (if known ) Congressional District (if known)
6 . Federal Department/Agency: 7 . Federal Program Name/Description:
CFDA Number (if applicable )
8 . Federal Action Number (if known) 9 . Award Amount (if known ) $
10. a. Name and Address of Lobbying Entity b. Individuals Performing Services (including address if
(if individual, last name, first name, Ml): different from No. 10a. ) (last name, first name, Ml):
(attach Continuation Sheet(s) SF-LLL A, if necessary) (attach Continuation Sheet(s) SF-LLL A, if necessary)
11 . Amount of Payment (check all that apply): 13. Type of Payment (check all that apply):
$ € actual € planned ❑ a. retainer
❑ b. one-time fee
12. Form of Payment (check all that apply): Elc. commission
❑ do contingent fee
❑ a . cash ❑ e. deferred
❑ b. In-kind ; specify: Nature ❑ f. other; specify:
Value
14 . Brief Description of Services Performed or to be Performed and Date(s) of Services , including officer(s), employee(s) , or
Member(s) contacted, for Payment Indicated in Item 11 (attach Continuation Sheet(s) SF-LLL A, if necessary):
15. Continuation Sheet(s) SF-LLL-A attached: ❑ Yes ❑ No
16 . Information requested through this form is authorized by Signature:
title 31 U . S . C. section 1352 . This disclosure of lobbying
activities is a material representation of fact upon which Print Name:
reliance was placed by the tier above when this transaction
was made or entered into. This disclosure is required Title:
pursuant to 31 U . S . C. 1352. This information will be
reported to the Congress semi-annually and will be Telephone No: Date:
available for public inspection. Any person who fails to file
the required disclosure shall be subject to a civil penalty of
not less than $ 10,000 and not more than $ 100,000 for each
such failure. Room
f tlelrel LJse:On%11 %,y Authorized for Local Reproduction
Standard Form - LLL
Docusign Envelope ID: 50585F21 -A738A303-BD3F-60841076ED5E
State Certifications Contract Number 00048145 / Page 30 of 30
Grantee/Contractor Certifications Required by North Carolina Law
Instructions : The person who signs this document should read the text of the statutes and Executive Order listed below and consult
with counsel and other knowledgeable persons before signing. The text of each North Carolina General Statutes and of the Executive
Order can be found online at :
• Article 2 of Chapter 64: http ://www.ncga ,state.nc.to/EnactedLegislation/Statt tesZPDFBvArticle/Chapter 64/Article 2 ,pdf
• G. S . 133 -32 : htto ://www.ncga . state.nc .its/gascripts/stahrtes/statiitelookiM.pl?statute= l33 -32
• Executive Order No. 24 (Perdue, Gov. , Oct. 1 , 2009) : https ://ethics.nc . gov/media/242/download?attachment
• G. S . 105464. 8 (b) : http://wwrv.iicga state nc us/EnactedLeOslation/Stahrtes/PDFBy5ection/Chapter 105/GS 105 - 164 . 8.af
• G. S . 14348 . 5 : httn ://wvvw.ncga.state,nc.us/EnactedLegistation/Statutes/1-TTMIJBySection/Chapter_143/GS 14348 . 5 .1itm1
• G. S . 143 -59 . 1 : http://wr%vw.ncga.state.nc.us/EnactedLeeaslation/Statutes/PDFBySection/Chauter 143/GS 143 -59. 1 .pdf
• G. S . 143 -59 . 2 : http :/Avww.ncga. state.nc.us/EnactedLegislation/Stattites/PDFBySection/Chapter 143/GS 143 -59?.ydf
• G. S . 143433 . 3 : http ://wwrv.ncsa.state.nc .us/EnactedLeeislation/Statutes/HT1vIIJBVSectioiVChapter 143/GS 143433 . 311tm1
• G. S . 143B439 .6C : http://tvww.ncaa. state.nc.us/EnactedLeeislation/Statiites/PDFBySection/Chapter 143B/GS 143B - 139.6C.pdf
Certifications
( 1 ) Pursuant to G.S. 133-32 and Executive Order No. 24 country" as set forth in G. S . 143 -59 . 1 (c)(2) after
(Perdue, Gov., Oct. 1 , 2009), the undersigned hereby certifies December 31 , 2001 but the United States is not the
that the Grantee/Contractor named below is in compliance principal market for the public trading of the stock of
with, and has not violated, the provisions of either said statute the corporation incorporated in the tax haven country.
or Executive Order. (4) Pursuant to G.S. 143-59 . 2(b), the undersigned hereby
(2) Pursuant to G.S. 143-48.5 and G.S . 143-133 .3, the certifies that none of the Grantee/Contractor's officers,
undersigned hereby certifies that the Grantee/Contactor directors, or owners (if the Grantee/Contractor is an
named below, and the Grantee/Contractor' s subcontractors, unincorporated business entity) has been convicted of any
complies with the requirements of Article 2 of Chapter 64 of violation of Chapter 78A of the General Statutes or the
the NC General Statutes, including the requirement for each Securities Act of 1933 or the Securities Exchange Act of 1934
employer with more than 25 employees in North Carolina to within 10 years immediately prior to the date of the bid
verify the work authorization of its employees through the solicitation.
federal E-Verify system. " E-Verify System Link: (5 ) Pursuant to G.S. 143B-139.6C, the undersigned hereby
www.uscis. e°v certifies that the Grautee/Contractor will not use a former
(3 ) Pursuant to G. S. 143 -59.1 (b), the undersigned hereby employee, as defined by G. S. 143B - 139.6C(d)(2), of the North
certifies that the Grantee/Contactor named below is not an Carolina Department of Health and Human Services in the
"ineligible Grantee/Contractor" as set forth in G. S . 143 - administration of a contact with the Department in violation
59. 1 (a) because : of G. S . 143B- 139. 6C and that a violation of that statute shall
(a) Neither the Grantee/Contactor nor any of its affiliates void the Agreement.
has refiised to collect the use tax levied under Article 5 (6) The undersigned hereby certifies further that:
of Chapter 105 of the General Statutes on its sales (a) He or she is a duly authorized representative of the
delivered to North Carolina when the sales met one or Grantee/Contactor named below:
more of the conditions of G. S . 105 - 164. 8(b) a and (U) He or she is authorized to make, and does hereby make,
(b) [check one of the following boxes] the foregoing certifications on behalf of the
® Neither the Grantee/Contactor nor any of its Grantee/Contactor; and
affiliates has incorporated or reincorporated in a "tax (C) He or she understands that any person who knowingly
haven county" as set forth in G. S . 143 -59. 1 (c)(2) submits a false certification in response to the
after December 31 , 2001 ; or requirements of G. S. 143 -59. land -59 .2 shall be guilty
❑ The Grantee/Contractor or one of its affiliates has of a Class I felony.
incorporated or reincorporated in a "tax haven
Grantee/Contractor' s
Name: Oran e & NFb :
Grantee/Contractor' s fiVautilS A4 VtA& 1/ 16/2025
Authorized Agent: Signature Date
Printed N �i'gffis n Title County Manager
SSa Q SbVi 1/17/202 5
Witness : Signature Date
Printed Name Melissa Allison Title Business Officer
The witness should be present when the Grantee/Contractor' s Authorized Agent signs this certification and should sign and date this
document irmnediately thereafter.
Contractor Certifications Required by North Carolina Law (Rev. 8/16;3/22;8/24) Page 1 of 1